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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: 1120635-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) asked a staff person (SP1) to go into the community, SP1 said, “No,” because SP1’s body was “tired,” and that SP1 and another staff person (SP2) restricted the VA’s access to pop and mocked the VA about his/her incontinence. It was also reported that SP1 donated the VA’s jeans without the VA’s consent. Date of Incident(s): Prior to March 12, 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); and subdivision 9, paragraph (b), clause (1): 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 25, 2026, from documentation at the facility; and through six interviews conducted with SP2, a facility management person (P1), and four facility staff persons (P2-P5). Attempts to contact SP1 to request an interview were unsuccessful. The VA’s guardian (G) did not respond to this investigator to provide information. The VA provided very limited information due to his/her abilities. The VA’s Annual Plan showed that the VA enjoyed shopping, listening to music, and spending time with his/her family. The plan showed that the VA had a mild developmental disability. A review of the VA’s plans did not show any restrictions on rights. The VA used oxygen and had an oxygen tank in his/her bedroom and an air tube that allowed the VA to walk about 25 feet within the facility. When the VA accessed the community, the VA used a portable oxygen tank. P1 said that on March 12, 2026, P1 received a call from P2 because the G expressed some concerns to P2 related to how SP1 and SP2 interacted with the VA. As a result, P1 went to the facility and P1 and P2 talked to staff and the VA. P1 remembered that a staff person said that most of the VA’s jeans were missing and found in a donation box in the garage, but P1 did not remember who told him/her that. The clothing was returned to the VA. When P1 asked SP1 about that, SP1 said that s/he put the jeans in the donation box because the VA told him/her that the jeans no longer fit the VA. When P1 talked to the VA, the VA provided limited information but stated that SP1 and SP2 were “mean” to the VA and that SP1 would not take the VA to his/her favorite store, but the VA did not provide additional information. P2 provided the following information: · P2 did not remember specific dates, but in February 2026, P2 heard from P3-P5 that SP1 and SP2 restricted some of the VA’s rights, such as not allowing the VA to drink his/her pop, which the VA purchased, telling the VA that s/he would need to make his/her own breakfast, and not allowing the VA to have what s/he wanted for breakfast. SP1 denied restricting any of the VA’s rights. After the concerns were brought forward to P2, P2 conducted a retraining with all staff related to rights restrictions. P2 did not witness any concerns related to SP1’s and SP2’s interactions with the VA. · On an unspecified date in March 2026, the G told P2 that when s/he had been at the facility, the G heard SP2 tell the VA that s/he could not have pop and that SP2 told the G that the VA was incontinent with urine and that the VA acted like a “baby.” When P2 talked to SP2, SP2 said that when s/he had to change the VA’s adult undergarments, SP2 did not like doing so because the VA was an “adult” and should not need to wear them. The G did not remember how the VA responded to those comments or whether the VA was not present when those comments were made. When the VA told the G that SP1 would not take the VA into the community, the G asked SP1 why. SP1 responded to the G that s/he was “tired.” · When P2 was asked to describe the interactions s/he observed with SP1, P2 said there was one time that SP1 was “upset” that the VA used a urinal because SP1 was concerned that the VA would spill urine while using it. P2 was not aware of a time that the VA spilled urine when s/he used the urinal. P2 did not remember the date but remembered a time that the VA’s urinal went missing and was found in the garbage, but P2 did not remember who found it in the garbage. When P2 asked SP1 if s/he was responsible for throwing away the urinal, SP1 denied doing so.
· P2 did not hear SP1 or SP2 make any negative comments about the VA’s use of adult undergarments. P3 provided the following information: · P3 described SP1 as “incessantly pestering” the VA to do certain things, such as dressing, and not assisting the VA when the VA asked for assistance. · The VA preferred to use the urinal at nighttime. At some point, SP2 told P3 that s/he did not like the VA using the urinal because there were instances when the VA spilled urine when using the urinal. P3 recalled a time that the urinal was missing during the summer of 2025. A day or so later, a new urinal was purchased for the VA and that one also went missing a few weeks later and P3 suspected that SP2 was responsible for the missing urinals. The VA would not have the ability to throw away the urinal on his/her own because the VA’s oxygen tube would not reach the garage. · P3 was not aware of a time that the VA was not allowed to have pop at his/her request. · P3 described both SP1 and SP2 as treating the VA like “children.” P3 gave examples in which SP1 and SP2 came to work and were “snapping” at the VA to clean his/her bedroom. The VA told P3 that s/he was “upset” when SP1 or SP2 talked to the VA in that manner and when they would not assist the VA with dressing. On at least one occasion, P3 heard SP1 and SP2 mocking the VA when the VA, who was not present, was incontinent in his/her adult undergarment. On different occasions and when the VA was not present, P3 heard SP2 say that s/he was too old to wear adult undergarments and SP1 said that the VA was a “baby” because s/he wore adult undergarments. · P3 was aware that some or all of the VA’s jeans went missing, but P3 did not have information related to that. P4 provided the following information: · P4 did not remember specific dates, but there were times that the VA had difficulty dressing and asked SP1 for assistance and P4 heard SP1 say that s/he would not assist the VA. When SP1 did not assist the VA, P4 stepped in and assisted the VA. P4 remembered another incident where SP1 talked to other clients, but not to the VA. When the VA talked to SP1, SP1 said, “I am not talking to you.”
· P4 remembered times that the VA would ask for four eggs (the VA normally ate three eggs for breakfast) and when that happened, SP1 told the VA s/he was only allowed to have three and if the VA wanted more, the VA had to make them. · P4 did not remember the date but remembered one time when SP1 was told that the VA had urinated on the floor so SP1 refused to take the VA on an outing that day. SP1 also yelled at the VA that s/he was a “grown” man/woman and that s/he should not be having incontinence accidents. When that happened, the VA’s eyes “filled with tears.” P4 told the VA that if SP1 did not take the VA out in the community, P4 would. · P4 remembered times that both SP1 and SP2 restricted or attempted to restrict the amount of pop that the VA could drink per day. SP1 was more insistent about the restriction and even though SP2 advised the VA not to drink so much pop, SP2 let the VA drink pop when s/he wanted it. · When the VA’s pants went missing and were found in the donation box, P4 asked the VA if s/he participated in the decision to donate them and the VA said, “No.” P4 did not hear SP1 or SP2 make any negative comments about the VA’s use of adult undergarments. P5 provided information that was mostly consistent with the information provided by P2-P4 and added that SP1 treated the VA like a “child” and would not assist the VA with dressing. P5 said that SP1 also refused to make the VA breakfast if the VA wanted breakfast later than the other clients ate. P5 stated that although SP1 took the other clients on community outings, SP1 rarely took the VA on outings. SP2 provided the following information: · SP2 remembered a time that there was liquid on the floor and when SP2 saw that, SP2 asked the VA if it was urine or water from the VA’s water bottle. SP2 denied that s/he made fun of the VA for using adult undergarments. · SP2 acknowledged that when the VA asked for pop, SP2 tried to persuade the VA to drink water and the VA sometimes agreed to that, but SP2 denied restricting the VA’s access to pop. · SP2 denied throwing the VA’s urinal away and did not know who did it. · SP2 denied talking to the VA in a demeaning way and said that when the VA might be slow with responding, SP2 gave the VA time to process the request. However, SP2 saw an incident involving the VA and SP1 that concerned SP2. During that incident, the VA told SP1 that s/he was thought that s/he was going to fall and when that happened, SP1 offered no assistance to the VA and told the VA, “No, you are not going to fall.” The VA did not fall. The facility’s training records showed that all staff interviewed for this investigation and SP1 were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to March 2026. Relevant Minnesota Rules and Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that clients have the right to be treated with courtesy and respect. Conclusion: Regarding SP1: Concerns were reported that SP1 restricted the VA’s access to his/her pop, that SP1 did not take the VA into the community, that SP1 would not make the VA breakfast, and that SP1 mocked the VA for being incontinent. The VA stated that SP1 was “mean” to the VA. SP1 told the G that s/he did not take the VA into the community on one occasion because SP1 was tired. P3 stated that SP1 did not assist the VA with dressing when the VA asked for assistance. SP1 made comments about the VA being incontinent and being a “baby” to others but the VA was not present. On one occasion, P4 stated that SP1 “yelled” at the VA and told the VA s/he would not take the VA on a community outing because the VA was incontinent and was a “grown” person and should not be having incontinence accidents. P4 said s/he would take the VA out. SP1’s behavior was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and in violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that the VA was not present when SP1 called him/her “baby,” that when SP1 yelled at the VA and would not take the VA into the community that was a single incident, and information from staff person interviews was not consistent regarding SP1’s actions, there was not a preponderance of the evidence whether SP1’s conduct was repeated or rose to the level of emotional abuse, and could reasonably be expected to cause emotional distress. Regarding SP2: Concerns were reported that SP2 restricted the VA’s access to his/her pop and SP2 mocked the VA for being incontinent. The G stated that SP2 told the G the VA was a “baby,” but the G did not know if the VA was present when SP2 said that which was behavior inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. SP2 stated that s/he did not restrict the VA’s pop but encouraged the VA to drink water and SP2 denied making comments about the VA’s undergarment. Therefore, given there was no information that showed the VA did not get his/her pop when s/he wanted it when SP2 worked and that the VA was not present when SP2 referred to the VA as a “baby,” there was not a preponderance of the evidence whether SP2 engaged in conduct that was repeated and would be reasonably expected to produce emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing). Regarding the VA’s jeans: Although SP1 placed them in a box to be donated, given that the jeans were not donated, did not leave the facility, and were returned to the VA, there was a preponderance of the evidence that the VA’s property was not disposed of in the absence of legal authority. It was determined that financial exploitation did not occur (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Action Taken by Facility: The facility completed a Vulnerable Adult Internal Review Addendum and determined that although policies and procedures were adequate, SP1 and SP2 did not follow the facility’s policy on “Employee Professionalism and Conflicts of Interest.” The facility provided additional training for all staff. In addition, SP1 was no longer employed by the facility and SP2 received a “Probationary Employee Counseling Report.” Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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