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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: 1071293-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed, choked, and “smacked” two vulnerable adults (VA1-VA2). Date of Incident(s): Multiple Incidents in October to December 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 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. 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 January 22, 2026; from documentation at the facility; and through six interviews conducted with VA1, VA2, two facility staff persons (P1 and P2), a facility supervisor (P3), and VA1’s guardian (G1). VA2’s guardian (G2) was contacted via phone call but did not call this investigator back to provide information for this investigation. An attempt was made to contact the SP by phone call, and a voicemail was left, however the SP did not respond. An interview request was sent by mail, and the SP also did not respond to the request The initial reported information stated that the SP engaged in aggressive behavior toward all four persons receiving services at the facility (VA1, VA2, and two other facility residents). However, within the investigation there was no information that the SP’s engaged in alleged maltreatment toward the two other facility residents, only VA1 and VA2. VA1 and VA2 were interviewed, however due to their limited verbal skills neither interview provided information regarding the allegations. Facility documentation showed VA1 enjoyed seeing his/her family on weekends, and wanted to have a significant other. VA1 valued making choices on what s/he wanted to do, and spending time how s/he pleased. VA1 felt it was important to celebrate his/her religion, and liked getting out into the community. VA1 was able to ambulate independently, but had difficulty seeing steps, and moving on slippery surfaces and uneven terrain. VA1 was diagnosed with developmental disabilities, obsessive-compulsive disorder, and other physical health issues. Facility documentation showed VA2 enjoyed spending time with friends and family. VA2 spent time watching TV, talking with people, and going on walks in the neighborhood. VA2 liked to do everything him/herself, and wanted to have control of everything. VA2 was diagnosed with developmental disabilities, obsessive-compulsive disorder, bi-polar disorder, depression, anxiety, and other physical health issues. During the investigation there was information that VA2 had previously sustained an injury to his/her leg, had physical therapy exercises that were recommended, and used a walker due to the injury. VA1’s and VA2’s Individual Abuse Prevention Plans (IAPP) showed VA1 and VA2 were both at risk for physical abuse. VA1 and VA2 were unable to identify dangerous situations, and staff persons were to redirect the VAs to a safe location in situations of potential physical abuse. The facility completed Incident Report(s) which provided the following information: · P1 and P2 informed P3 they observed the SP being aggressive with VA1. The interactions P1 and P2 described included the SP grabbing VA1’s neck, the SP “choke[ing]” VA1, and the SP “smack[ing]” VA1 in the back of the neck. · P1 and P2 informed P3 they observed the SP being aggressive with VA2. The aggressive interactions included the SP pushing VA2 in the back, grabbing VA2 by the neck, and the SP “smack[ed]” VA2 in the back of the neck. The physical interactions occurred after VA2 did not comply with completing physical therapy exercises. · The SP was interviewed by facility administration regarding the alleged interactions and said s/he would never hurt VA1 or VA2. P1 provided the following information: · P1 said on unknown dates s/he observed the SP try and grab items out of VA1’s hands (VA1 had a program in which s/he could take a certain number of items with him/her while leaving the facility, but VA1 would try and take more than allowed). P1 said on at least two occasions s/he observed the SP attempt to take items from VA1. P1 said VA1 refused to give the items to the SP, so the SP put his/her hands around VA1’s neck, and “just choke[d]” VA1 until VA1 gave the items to the SP. P1 added the SP had also used one hand on the back of VA1’s neck and used his/her other hand to take VA1’s items. P1 also said the SP threatened to cancel activities or plans for VA1. P1 said VA1’s breathing was not restricted, but when the SP’s hands were on VA1’s neck/throat, VA1 did not move. P1 did not observe any injuries during the interactions, but felt the SP was provoking VA1 during the incident as the SP threatened to cancel planned activities if VA1 spit on the SP during the interaction. · P1 told the SP that s/he did not need to “do this,” (referring to the incident in which the SP put his/her hands on VA1’s neck/throat) and the SP responded to P1, “This is something that you would never have to do, and this is just something I can do.” P1 said the physical interaction between the SP and VA1 was due to VA1 attempting to leave the facility with more personal items than was planned. · P1 said there was a day VA2 refused to complete a physical therapy routine with P1, and spit on P1. P1 stated it was not a “big deal,” but the SP responded by going over to VA2, who started to walk away from the SP (using his/her walker), and the SP “smack[ed]” VA2 in the neck with an open hand, grabbed VA2 by the neck, and turned VA2 toward the SP. · P1 said on a different unknown date a physical therapist was at the facility and shared with P1 that while at the facility the physical therapist had witnessed the SP “smack” VA2 in the neck. · P1 was unsure of the dates in which the above incidents occurred, but stated the incidents occurred between October and December 2025. P2 provided the following information: · P2 said in later November or early December 2025, s/he observed the SP “push” and “grab” VA1 and VA2 while P2 was being trained at the facility. P2 said the SP’s interactions with VA1 occurred in the staff office, and when VA1 had more items than s/he was allowed. P2 said the SP engaged in the interactions with VA2 when s/he was not participating in his/her physical therapy. P2 said s/he witnessed at least three incidents in which the SP either pushed or grabbed VA1 and VA2. · P2 said VA1 and VA2 were not injured during the interactions. P3 said P1 and P2 informed him/her of the SP’s interactions with VA1 and VA2, but P3 did not witness any concerning behavior by the SP. P3 said VA1 and VA2 had positive changes in their behavior after the SP no longer worked at the facility. P3 did not observe any injuries to VA1 or VA2 that were caused by the SP. G1 said s/he witnessed the SP be verbally aggressive with VA1, but G1 did not observe any physical aggressiveness by the SP toward VA1. G1 said the SP would be “stern” with VA1, but did not observe any name calling. LE was contacted but had not started an investigation at the time of this report. The facility’s Emergency Use of Manual Restraints (EUMR) Policy stated the use of an emergency use of manual restraint was meant as a physical restraint when a person posed an imminent risk of physical harm to self or others and it was the least restrictive intervention that would achieve safety. Property damage, verbal aggression, or a person's refusal to receive or participate in treatment or programming on their own, did not constitute an emergency. The SP’s job description stated the SP’s job requirements assured that services and activities complied with licensing regulations, along with the facility’s policies and person-centered philosophy. The SP was also expected to exercise good judgement to adapt and apply the guidelines to specific situations. It also stated all employees were expected to model and champion the facility’s core values: Person-Centered, Relational, Opportunistic and Stewardship in order to provide people with intellectual and other disabilities, the opportunity to live life to its fullest. P1, P2, P3, and the SP received training on VA1’s and VA2’s client specific programming, the Reporting of Maltreatment of Vulnerable Adults Act, and the facility’s policies and procedures, which included the EUMR policy. Conclusion: A. Maltreatment: Client specific plans for VA1 and VA2 showed both were vulnerable to physical abuse. The facility’s policies and procedures permitted staff persons to block the VA’s limbs or body as the least restrictive method of physical contact. VA1 and VA2 were limited verbally, and unable to provide information related to the alleged maltreatment. There was no information that during the alleged incidents that VA1 and VA2 were harming any other person or themselves. This investigator attempted to contact the SP; however, the SP did not respond to the interview request. Regarding alleged physical abuse of VA1:
P1 said on unknown dates s/he observed the SP try and grab items out of VA1’s hands. During those interactions P1 observed the SP put his/her hands around VA1’s neck, and “just choke[d]” VA1 until VA1 gave the items to the SP. P1 also observed the SP hold VA1 by the back of his/her neck and use his/her other hand to take VA1’s items. P1 said VA1’s breathing was not restricted, and VA1 was not injured, but when the SP’s hands were on VA1’s neck/throat, VA1 did not move. P2 said s/he observed the SP “push” and “grab” VA1 when VA1 had more items than s/he was allowed. Although there was no information that VA1 was injured, given that P1 saw the SP put his/her hands around VA1’s neck, “just choke” VA1, and grab VA1’s neck while taking an item from VA1’s hands, and that P2 saw SP1 “push” and “grab” VA1, there was a preponderance of the evidence that the SP’s conduct was non-accidental and would be reasonably expected to produce pain or injury. It was determined that 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). Regarding alleged physical abuse of VA2: P1 said on an unknown date VA2 refused to complete a physical therapy routine with P1, and spit on P1. P1 said the SP responded by going to VA2, and “smack[ing]” VA2 in the neck with an open hand, grabbing VA2 by the neck, and turning VA2 toward the SP. P2 said the SP engaged in the interactions of pushing or grabbing VA2 when VA2 would not participate in his/her physical therapy. P1 and P2 said VA2 was not injured during the interactions. Although VA2 was not injured, give that P1 and a physical therapist saw the SP “smack” VA2, and that P2 saw the SP push and grab VA2, there was a preponderance of the evidence that the SP’s conduct was non-accidental and would be reasonably expected to produce pain or injury. It was determined that 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). Regarding the allegation of neglect: Given that P1 and P2 each stated they saw the SP use physical intervention when there was not an imminent risk of harm including the SP going after VA2 as VA2 walked away using a walker to stop VA2, and grabbing VA2 by the neck to turn VA2 back around, that the SP threatened to take away activities, and that the G stated that the SP was verbally aggressive, there was a preponderance of the evidence that there was a failure to provide VA1 and VA2 with reasonable and necessary care and services. 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). 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 trained on VA1’s and VA2’s client specific documentation, the facility’s EUMR policy, and the reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP was responsible for the maltreatment. 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 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 physical abuse which the SP was responsible was not “serious” maltreatment because it did not meet the definition, however, were both “recurring” maltreatment because there was more than one incident of physical abuse and the neglect involved two VAs. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, but not followed by the SP. The alleged incident was not similar to past events, and no additional training was completed. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that two staff persons failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures.
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