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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: 1069999-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Beth Virden Suspected Maltreatment Reported: Allegation One: It was reported that more than once, a vulnerable adult (VA1) had unexplained bruises on his/her arms and legs. Allegation Two: It was reported that VA1 had unexplained bruises around his/her genitalia. Allegation Three: It was reported that more than once, vulnerable adults (VA1, VA2, and VA3) were missing their medications and/or received incorrect dosages of their medications. Date of Incident(s) for Allegations One and Three: Ongoing Date of Incident(s) for Allegation Two: December 1 or 2, 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 (1); and subdivision 2, paragraph (c); 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' include the primary genital area, groin, inner thigh, buttocks, and breast. 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 5, 2025; from documentation at the facility and medical records; and through 17 interviews conducted with VA1’s, VA2’s, and VA3’s guardians (G1, G2, and G3, respectively), VA1’s-VA3’s case manager (CM), facility staff persons (P1-P5) and a supervisory staff person (P6), a hospital registered nurse (RN) and a medical doctor (MD), staff from VA1’s day services facility (DSF1 and DSF2), VA2, VA3, and the SP. VA1 was not interviewed due to his/her limited communication skills. VA1’s, VA2’s, and VA3’s support plans provided the following information: · VA1, VA2, and VA3 lived together at the facility, which was a single-family house. The facility provided VA1-VA3 with services and support relating to their diagnoses, which included intellectual disabilities. The facility provided at least one staff person 24 hours a day to help with meal preparation, hygiene, activities of daily living skills, transportation, mobility, and communication. · VA1 was a homebody and enjoyed using his/her iPad and watching television. VA1 might speak in one-word sentences, like saying, “Cheeseburger,” when s/he was hungry or, “Night,” when s/he wanted to go to bed. VA1 also used some sign language to communicate, including pointing at items in a room. · VA2 enjoyed joking with others, visiting family, bowling, and dancing. VA2’s verbal communication might be “difficult to understand,” and s/he used gestures to help communicate if needed. · VA3 enjoyed planning meals, going on vacations, and bowling. VA3 communicated verbally. Relevant Minnesota Rules and Statutes: Minnesota Statutes section 245D.09, subdivision 4a, paragraph (c) stated that before having unsupervised direct contact with a person served by the program, the staff person must review and receive instruction on the person’s support plans as they relate to the staff person’s job functions for that person. Facility documentation stated that the SP and P1-P6 received training on the Reporting of Maltreatment of Vulnerable Adults Act. P1 received training on VA1’s, VA2’s, and VA3’s support plans, but the facility did not have documentation that the SP and P2-P6 received training on all VA1’s, VA2’s, and VA3’s support plans, which was a violation of Minnesota Statutes section 245D.09, subdivision 4a, paragraph (c). Allegation One: It was reported that more than once, VA1 had unexplained bruises on his/her arms and legs. VA1’s support plans, including Individual Abuse Prevention Plan, stated that VA1 was susceptible to physical abuse from others and would be unable to escape, avoid, report, or defend him/herself if necessary. Staff were to intervene in potentially dangerous situations; monitor VA1 for signs and symptoms of abuse, which might include unexplained bruises; and report concerns on VA1’s behalf. The CM said that on November 20, 2025, P4 emailed regarding ongoing concerns of unexplained bruises on VA1 and P4’s observations that VA1 “displayed behavior changes when [the SP] is around.” The CM did not see VA1’s bruises but added that VA1 did not have a history of causing bruises to him/herself. The staff’s daily notes for VA1 during October and November 2025 provided the following information: · More than once a week, VA1 hit, scratched, and/or pinched staff; and appeared “anxious or restless” with “sudden outbursts” of crying or screaming. VA1 routinely stomped his/her feet, “pounded on things,” kicked a table or ran into a counter, and/or climbed on a chair into a pantry. More than once, VA1 had ingrown hair, which presented on his/her skin as a red dot with a white center. · On October 14, 2025, VA1 was repeatedly itching his/her back and calves. Staff applied lotion and saw a red scratch across VA1’s chest and “bilateral bruising” on his/her shins and “minor bruising” on his/her left knee. [Note: Staff did not always document a description of the bruises, including size or color.] · On October 26, 2025, staff saw a “half dollar size blue bruise” on VA1’s right knee and a “fingernail size” bruise on his/her inner left thigh. · On October 30, 2026, VA1 was repeatedly itching his/her left underarm and staff saw a “small (quarter size) red spot” in the area. · On November 5, 2025, during VA1’s morning bath, staff saw bruises on VA1’s shin, forearm, thigh, hip, and shoulder, which were not present “last night.” · On November 19, 2025, staff saw a bruise on VA1’s right inner knee. · On November 20, 2025, staff saw a scratch on VA1’s right upper hip area. · On November 21, 2025, staff saw a bruise on VA1’s left knee. · On November 24, 2025, staff saw “redness” on VA1’s right shoulder and a “new bruise” on his/her right shin. VA1’s medical records for December 4, 2025, stated that the MD noted “overall diffuse bruising” (spread over a wide area), which was mostly resolved (healing). The MD did not make any statement about the cause or source of the bruises. P1-P6 provided the following consistent information: · Around October and November 2025, VA1 sustained a noticeable increase in unexplained bruising on his/her legs, shoulders, and arms. The bruises were typically about the size of a quarter (coin) or smaller and were various shades of blue or brown. Some of the bruises looked like “fingerprints” or might be consistent with someone squeezing VA1 or “grabbing hard.” · Some staff stated that VA1’s bruises seemed to consistently appear following the SP’s shifts and that VA1 seemed to have “increased anxiety and agitation” when the SP was around. [Note: Facility documentation showed that the SP’s employment started in early October 2025 and ended in early December 2025.] · P1-P6 did not engage in conduct that might have caused VA1’s bruises and they did not witness the SP engaging in conduct that might have caused VA1’s bruises. · VA1 did not have a history of self-injurious behaviors, which might cause a bruise. However, VA1 had a history of kicking a table or chair leg, falling out of bed, and climbing into a pantry. The SP said that s/he did not cause VA1’s bruises or know what might have caused VA1’s bruises. DSF1 said that s/he was not aware of bruises on VA1. Once, on an unrecalled date, the facility notified the day services facility that VA1 fell and sustained bruises. DSF1 was not aware of VA1 engaging in self-injurious behaviors, which might cause a bruise. DSF2 said that s/he was not aware of conduct at the day services facility, which might cause a bruise to VA1. VA1 had a history of scratching staff and him/herself. It was “normal” for VA1 to have “dark spots” on his/her legs. On January 16, 2026, staff noticed VA1 had “redness … a little more red than normal” on his/her legs. [Note: In January 2026, the SP no longer worked at the facility.] G1 said that VA1 might cause bruises by scratching him/herself or dancing. Conclusion for Allegation One: Consistent information was provided by P1-P6 and the staff’s daily notes that more than once, VA1 had unexplained bruises. Although some staff believed VA1’s bruises consistently appeared after the SP’s shifts, the SP denied causing VA1’s bruises and no one saw the SP engage in conduct, which might have caused VA1’s bruises. In addition, at least some of VA1’s bruises occurred when the SP was no longer working at the facility and VA1 routinely engaged in other behaviors, which might have caused bruises to him/herself. Therefore, there was not a preponderance of the evidence whether a staff person’s conduct, which was not accidental or therapeutic, produced or could reasonably be expected to produce physical pain or injury to VA1. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Allegation Two: It was reported that VA1 had unexplained bruises around his/her genitalia. VA1’s support plans, including Individual Abuse Prevention Plan, stated that VA1 was susceptible to sexual abuse from others and would be unable to escape, avoid, report, or defend him/herself if necessary. Staff were to intervene in potentially dangerous situations; monitor VA1 for signs and symptoms of sexual abuse, which might include unexplained trauma to his/her genital or anal area; and report concerns on VA1’s behalf. P1-P6 provided the following information: · P3 said that on December 1, 2025, prior to 8:30 a.m., s/he helped VA1 take a bath and then applied VA1’s creams and lotions, which included application to VA1’s intimate parts. P3 did not notice any discoloration or concerns with VA1’s genitalia at that time. At 3 p.m., P2 and the SP arrived, and P3 left. · P2 said that later in the evening, on December 1, 2025, s/he helped VA1 take a bath and then applied VA1’s creams and lotions. [Note: Staff helped VA1 bathe and reapply his/her creams and lotions twice daily.] P2 did not note any concerns at that time. Around 8 p.m., VA1 got into bed in his/her bedroom and VA1’s bedroom light was turned off. At 9 p.m., P2’s shift ended, which left the SP as the sole staff person between 9 and 10 p.m. P2 said that as s/he was leaving in his/her vehicle from the facility’s driveway, s/he saw VA1’s bedroom light turned on. P2 was not immediately concerned because VA1 had a history of getting up throughout the night to use the restroom. · P3 said that at 10 p.m., s/he arrived at the facility in relief of the SP. At that time, the SP was sitting in the living room and appeared “quieter than normal.” The SP might engage in “small talk” at shift change but did not do so on December 1, 2025. VA1 was in bed and the SP left soon after. · P4 said that on December 2, 2025, around 5 or 5:30 a.m., s/he helped VA1 take a bath and then while applying VA1’s creams and lotions, noticed “very dark” skin surrounding VA1’s anus, which was “not typical.” P4 was not immediately concerned and believed VA1 had developed a rash. P4 applied extra cream and then continued with the day. On December 4, 2025, P4 again helped VA1 undress for his/her hygiene cares and again saw discoloration around VA1’s anus but this time, P4 believed it looked like a bruise and not a rash. P4 contacted P6, who contacted law enforcement, and P4 brought VA1 to an emergency room for an evaluation. · P1-P6 each said that some staff believed the discoloration around VA1’s anus likely occurred at some point between VA1’s evening bath on December 1, 2025, and morning bath on December 2, 2025. The SP was the sole staff person between 9 and 10 p.m., on December 1, 2025; and P3 was the sole staff person between 10 p.m., December 1, 2025, and 5 a.m. on December 2, 2025. P3 said that s/he did not engage in conduct that might have caused the discoloration. Some staff believed the SP was likely responsible and pointed to VA1’s increased anxiety and agitation when s/he was around the SP. The MD, the RN, and VA1’s medical records provided consistent information that on December 4, 2025, VA1 arrived at the emergency room with “unexplained peri-anal bruising.” [Note: At that point, VA1 had taken at least four baths since the peri-anal bruising was first noticed on December 2, 2025.] The MD noted peri-anal tenderness and a little bleeding, which was “strange.” There was no evidence of fissures or tears. The RN tested VA1 for sexual transmitted illnesses and yeast infections, and all returned with negative results. The RN did not complete an internal examination due to concern of “unnecessary trauma” to VA1. The RN collected DNA and hair samples from the exterior of VA1’s genitalia and provided them to law enforcement officers (LEO). The LEO referred the DNA and hair samples to the Minnesota Criminal Bureau of Apprehension (BCA) for additional testing. The BCA tests did not show any DNA from another gender, and the hair sample was not suitable for analysis. [Note: The SP and P3 were not the same gender as VA1.] The LEO did not pursue charges. The SP said that s/he did not engage in conduct that might have caused a bruise around VA1’s anus. The SP sometimes saw discoloration but attributed it to a bout of diarrhea or VA1 “pushing too hard” when using the toilet. Conclusion for Allegation Two: On December 1, 2025, P2 and P3 each helped bathe VA1 and apply VA1’s creams and lotions and did not notice concerns. On December 2, 2025, P4 saw discoloration around VA1’s anus but believed it was a rash and did not seek medical attention at that time. On December 4, 2025, the discoloration remained and P4 brought VA1 to the emergency room. The MD, the RN, and VA1’s medical records provided consistent information that VA1 had unexplained peri-anal bruising, which was “strange.” There was no evidence of fissures or tears. The RN collected DNA and hair samples from the exterior of VA1’s genitalia. The samples did not show DNA from another gender, which included the SP and P3, who were working with VA1 during the timeframe when the bruising was believed to have occurred. Therefore, and without additional witnesses or evidence to indicate otherwise, there was not a preponderance of the evidence whether a staff person engaged in conduct which caused peri-anal bruising to VA1 or whether VA1 sustained the bruising by other means. It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' include the primary genital area, groin, inner thigh, buttocks, and breast). Allegation Three: It was reported that more than once, VA1, VA2, and VA3 were missing their medications and/or received incorrect dosages of their medications. VA1’s-VA3’s support plans, including Self-Management Assessments, provided the following information: · VA1 did not understand his/her medications and would likely ingest any pill that was handed to him/her by a staff person. VA1 was unable to follow medical instructions or manage his/her own health and safety. Staff were to set up and administer VA1’s medications as prescribed. · VA2 and VA3 each self-administered their own medications using their own DOSE Flip machine, which staff set up each week. [Note: A DOSE Flip is a small electronic pillbox that sounded an alarm at certain prescheduled times and then automatically opened a compartment containing medication.] The CM said that on an unspecified date, P4 and P5 emailed or called with concerns that VA1-VA3 were missing medications. VA2 and VA3 each said that they received their medications from their own DOSE Flip machine. Staff set up the DOSE Flip weekly, and VA2 and VA3 independently accessed their respective DOSE Flip at the scheduled times and self-administered their medications with staff supervision. VA2 said that s/he knew how many pills s/he took at each medication time. VA3 said that s/he counted his/her pills each time before taking them. One time, VA3 noticed that s/he was missing one pill and told the staff, who administered the missing pill from a different container. VA3 was not aware of times when there were extra pills in his/her DOSE Flip. P1-P6 provided the following information: · P1-P6 provided consistent information that during October and November 2025, P4 was responsible for setting up the clients’ medications, including VA2’s and VA3’s DOSE Flips. [Note: Staff administered VA1’s medications from blister packs.] · P4 and P5 each said that P4 always set up the clients’ medication correctly. More than once, P5 double-checked P4’s work and never saw concerns. However, more than once, on the same day as and after P5’s double-checks, there was a medication error and more than once the error was discovered by the SP. This included one time when a pill was missing but it was discovered the next day as having been moved into the next day’s compartment. Other times, medications were doubled up in a compartment or missing altogether. One time, the SP discovered an extra Lorazepam tablet (anticonvulsant) in a DOSE Flip compartment and did not administer it but put it back in the compartment. However, when staff went back to review what happened, the extra Lorazepam tablet was missing altogether, and the SP later said that s/he destroyed it. P4 and P5 each said that staff should not destroy medications if they were the sole staff person, and when the SP reportedly destroyed the extra Lorazepam tablet, s/he was alone. · P1-P6 each said that some staff believed the SP was responsible for the medication errors and that the SP was either taking the pills for his/her own use or the SP was intentionally causing the medication errors to make it appear that P4 “was losing [his/her] mind.” P1-P6 did not witness the SP taking or tampering with medications or the DOSE Flips. · P1-P6 each said that VA2’s and VA3’s DOSE Flip machines were stored in lockers, which all staff and VA2 and VA3 had access, and that each DOSE Flip could be “easily” opened with a standard screwdriver. · P1-P6 each said that they were not aware of any client receiving a double dose of a medication or missing a dose of a medication. However, VA1 had been experiencing increasing anxiety and agitation, which could be related to not always receiving all his/her medications. · Some staff expressed additional concerns and said that when P6 was informed of medication errors, s/he told staff, “Do not report the incident(s) outside of [the facility].” P6 said that s/he believed most of the medication errors occurred prior to his/her employment and that s/he saw medication errors reported via incident reports. Staff were trained to report suspected maltreatment to the Minnesota Adult Abuse Reporting Center and P6 would also investigate concerns when s/he was made aware. When P6 was informed of the medication errors occurring in October and November 2025, s/he immediately removed the DOSE Flips and instructed staff to start administering all medications from the blister packs, which had a better tracking system to identify missing or tampered medications. G2 said that VA2 would not be able to identify his/her pills and might not notice if one was missed or added. G3 said that s/he was not a fan of the DOSE Flip system but was not aware of errors occurring. Conclusion for Allegation Three: More than once, VA1’s-VA3’s medications were discovered missing or doubled up, and although VA1 experienced increased anxiety and agitation, there was no information that this was related to medication errors or that VA1 or VA2 or VA3 ever received an incorrect dosage. Consistent information was provided that the medication errors were discovered and corrected prior to administration. Although some staff believed the SP was responsible for the medication errors, the SP denied the allegations and P1-P6 did not witness the SP taking or tampering with medications. Information was also provided that all staff, and VA2 and VA3, had access to the DOSE Flip machines, which could be “easily” opened with a screwdriver. In addition, although some staff said that P6 told them not to report medication errors, P6 said that medication errors were reported via incident reports and when s/he became aware of concerns, s/he immediately removed the DOSE Flips to better identify missing or tampered medications. Therefore, and without additional witnesses or evidence to indicate otherwise, there was not a preponderance of the evidence whether a staff person’s conduct, which was not accidental or therapeutic, included a failure to supply VA1-VA3 with care or services, which were reasonable and necessary for their health and 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 policies and procedures were adequate but not followed as it pertained to staff always notifying an appropriate person of unexplained bruising on a client. The facility provided additional training to all staff regarding the expectations of reporting injuries of unknown origin and the Reporting of Maltreatment of Vulnerable Adults Act. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On April 2, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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