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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: 1123293-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Neubauer-Hoffman, Deb Deb.Neubauer-Hoffman@state.mn.us 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled, swore at, and belittled a vulnerable adult (VA1) who was frequently incontinent. In addition, the SP’s behavior towards VA1 upset another vulnerable adult (VA2) who said s/he did not feel comfortable talking about his/her concerns with the SP because the SP also shouted at VA2 when VA2 confided in the SP. Date of Incident(s): Prior to February 2, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. Summary of Findings: Pertinent information was obtained during a site visit conducted on February 10, 2026; from documentation at the facility; and through seven interviews conducted with VA1, VA2, four facility staff persons (the SP and P1-P3), and VA1’s guardian (G). Attempts to interview another staff person (P4) were not successful. VA1 enjoyed music, especially Bobby Vinton and Engelbert Humperdink. VA1 also liked going to libraries that had coffee shops. VA1’s diagnoses included mild intellectual disability, spinal meningitis, and paraplegia. VA1 used a wheelchair for all mobility. VA1’s plans showed the following information: · VA1’s Support Plan Addendum showed that staff persons provided “verbal encouragement” to use the bathroom every two hours to maintain his/her skin integrity. Regardless of prompts, VA1 was often incontinent multiple times per day. (Information showed that around 2023, VA1 developed open sores on his/her coccyx that required wound care services and a catheter. The catheter was eventually removed in December 2024.) · VA1 was prescribed a medication to treat overactive bladder, sudden urges to urinate, leaking bladder, and to help his/her bladder relax and hold more urine. · VA1’s Individual Abuse Prevention Plan stated that s/he “may make false claims or inaccurately report details.” · VA1 had virtual therapy appointments with a therapist every two weeks. VA2 enjoyed time with his/her family. VA2 was not subject to guardianship. VA2’s diagnoses included major depression, anxiety, high cholesterol, and osteoporosis. VA2’s Support Plan Addendum stated s/he was articulate and able to accurately report events and how s/he was feeling. Other than staff persons providing medication set up, assistance, and administration, VA2 preferred to be independent with all medical and dental appointments. (At the time of the investigation, VA2 was preparing to move into an apartment by him/herself.) The facility was a one-level side-by-side townhouse with two bedrooms on each side. The facility was converted into one four-bedroom facility. The north and south sides of the facility were a mirror reflection with the two bedrooms on each outside wall. The north and south side each had a living room and two bathrooms. A kitchen and dining area were located on the south side. VA1’s bedroom was located on the north side of the facility and VA2’s bedroom was on the south side of the facility. A tour of the facility showed the following note taped next to VA1’s bed: “[VA1’s name], This is your reminder to use the call button when you need to use the restroom. If you have an accident, use the call button to get up and clean up. Staff are here to help you stay clean and dry. Remember that your goal is to return to the day program and start making MONEY again $$$$$.” (Smile face emoji). “You can do this!!” P1 provided the following information: · P1 began working at the facility at the end of December 2025. During P1’s first few weeks at the facility, VA1 was “an emotional wreck” and cried “quite a bit,” and “it revolved around toileting time.” VA1 told P1 that the SP was “rude” to VA1 and “yelled” at VA1 when s/he was incontinent. P1 did not work with the SP and did not observe any interaction between the SP and VA1 and/or other residents. · P1 said that the SP “withheld services” such as signing VA1 up to attend a day program due to VA1’s incontinence. VA1 said that the SP told VA1 the day program “did not want [VA1] at the day program anymore because of the urinating.” The SP hung a note in VA1’s room that stated “if [VA1] “stops peeing” in his/her pants “[VA1] can go back to work and make money.” · VA2’s daily logs showed that when s/he was away from the facility, VA2 drank alcohol “a lot.” VA2 told P1 that on “multiple occasions” s/he heard the SP “verbally abusing” VA1 due to his/her incontinence issues” and that the SP made a “spectacle of [VA1] every time [s/he] had an accident, purposely embarrassing [VA1]” by “screaming obscenities” like “goddammit” and “fuck.” · VA2 told P1 that on one occasion when VA2 attempted to share concerns with the SP about staff persons “stealing” from the facility, the SP became very angry and stated s/he "didn't have time for this shit." As a result, VA2 was upset and did not feel comfortable with the SP. · While at a training (residents were not present), the SP made a comment about VA1’s “Pampers.” · P1 said that P2 worked the most with the SP and would be able to provide additional information. VA1 said that s/he was incontinent “every day” because s/he was paralyzed and did not have normal feeling from “the waist down.” When a staff person (P5) worked, P5 told VA1 s/he was “wet” in the presence of other residents resulting in VA1 feeling “embarrassed.” When asked about the note posted next to VA1’s bed, s/he said the SP made the note and the VA1 thought it was a “good idea” because s/he previously attended a day program but a “nurse” at the day program said they could not change VA1 as needed (referring to his/her toileting program every two hours) so VA1 stopped attending. VA1 initially denied that anyone swore at him/her. Later in the interview with this investigator when asked if anyone swore at or belittled VA1 because of his/her incontinence, VA1 said, “It happened.” However, VA1 did not “remember who did it.” VA1 said that s/he and the SP got along “fine” and said the SP was “more like [a family member]” to VA1 than some of VA1’s relatives. VA2 provided the following information: · VA2 said that s/he had incidents of conflict with P5 that “goes back two years.” When VA2 attempted to talk to the SP about those concerns, the SP “didn’t want to hear about it.” Eventually VA2, P5, and the SP had a meeting that resulted in VA2 being “disappointed” in the SP. · On more than one occasion VA2 was in his/her bedroom and woke up because s/he heard the SP “yell” at VA1. The SP said, “goddammit” and “what the fuck” when VA1 was incontinent or had “loose bowels.” P2 said that “three of the four” residents had incontinence issues and staff persons assisted the residents as needed. P2 did not remember any staff persons being impatient with the residents’ incontinence and “never” heard a staff person yell or swear at VA1, nor belittle or say disparaging comments about VA1 in the presence of other residents. VA1’s disposable undergarment was referred to as a “brief.” When asked about VA1’s and VA2’s ability to accurately report events, P2 said that VA1 “does tend more towards the dramatic” and made reports in the past about staff persons yelling at VA1 that were determined “not true.” Regarding VA2, P2 said VA2 drank alcohol “excessively,” was “not trustworthy,” and attempted to get other residents to “make up stories to try to get staff in trouble.” On at least one occasion, VA1 “admitted” that VA1 and VA2 made up stories about staff persons. P2 had no concerns regarding how the SP talked with or treated the residents. P3 provided the following information: · VA1 needed verbal prompts “every two hours” to use the bathroom. Staff persons assisted VA1 into the bathroom and changed his/her brief as needed. Staff persons referred to VA1’s disposable underwear as “briefs” or “pull ups” depending on the type of undergarment. · P3 worked with the SP every other weekend for six months and “never” saw or heard the SP do or say anything that concerned P3. P3 “never” observed the SP angry with any of the residents. The G said that the SP worked with VA1 for years. The G believed the SP “loved [VA1],” and was “very good” to VA1. Regarding VA1’s ability to accurately report events, the G said that VA1 “has been known to fib.” The G believed that VA1 was incontinent “on purpose” resulting in the G telling VA1 that the G would not pay for his/her cell phone service until VA1 stopped being incontinent. The SP provided the following information: · VA1 resided at the facility since 2009 and had a “bathroom program” since s/he moved in. VA1 had a “toilet program” implemented every two hours when VA1 was awake. Around 2023, VA1’s incontinence resulted in sores on his/her coccyx that remained for over a year and required bed rest to heal. At that time VA1 stopped attending a day program. The SP believed VA1 was a “false reporter;” however, was “honest about certain things.” The SP denied swearing at VA1 or any other resident. The note next to VA1’s bed about calling for assistance during the night was a suggestion from VA1’s therapist as the therapist believed a visual reminder would help. The SP asked VA1’s permission before putting the note up next to VA1’s bed. · VA2 resided at the facility since 2023 and was “very independent.” Due to VA2’s alcohol use, the SP did not believe VA2 was an accurate reporter of events because s/he was not able to “remember things correctly.” The SP said there were times when s/he met with VA2 to discuss VA2’s concerns about facility staff persons. The discussion resulted in the SP believing VA2 “misinterpreted” situations because VA2 then asked the SP “not to talk to staff about what [VA2] said.” · At the time of the investigation, the SP no longer worked at the facility and said s/he was “blindsided” that anyone would say s/he yelled or swore at VA1 or any of the residents. The SP said s/he “never” raised his/her voice with VA1 and always tried to “remind” VA1 about the importance of keeping VA1 clean and dry to avoid sores. Facility documentation showed that staff persons received training specific to VA1 and VA2, and training on the Reporting of Maltreatment of Vulnerable Adults Act, individual rights, and positive behavior supports prior to the allegations. Conclusion: VA2 said on more than one occasion s/he woke up because the SP was yelling and swearing at VA1 when VA1 was incontinent. The SP denied the incidents occurred. Although the SP had reason to minimize his/her actions for fear of consequences, P2 and P3 worked regularly with the SP and each had no concerns regarding the SP’s interactions with VA1 or any of the residents. In addition, although VA1 said, “It happened,” s/he did not remember who or what was said and did not provide additional information regarding the allegations. Although VA2 stated that s/he heard the SP talk to VA1 in this manner, given that information showed VA2 had interpersonal conflict with the SP about a concern s/he brought up to the SP two years ago, and that VA2’s bedroom was on the opposite side of the facility making it unlikely such incidents occurred without anyone else hearing them, there was not a preponderance of the evidence whether the SP engaged in non-therapeutic conduct that would reasonably be expected to cause VA1 or VA2 emotional distress. It was not determined whether emotional abuse occurred (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 procedures were followed and were adequate. Expectations regarding respectful communication, and maintaining dignity and privacy of individuals were reviewed with staff persons, as well as the prohibition of punitive responses to medical or disability-related needs. 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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