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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: 1083654-AFC (Adult Foster Care) Investigator(s): Jason Pehler/Beth Virden Suspected Maltreatment Reported: Allegation One: It was reported that a vulnerable adult (VA) had multiple unexplained, “fingerprint-sized” bruises on his/her back. Allegation Two: It was reported that staff held the VA down to complete his/her cares and tied the VA to his/her wheelchair and locked the VA in his/her bedroom to prevent “behaviors.” Alleged Licensing Violations: It was reported that staff conduct included: · Changing the VA’s medication and diet without a doctor’s order. · Destroying staff documentation in the VA’s progress notes. · Disallowing visits from the VA’s family members. Date(s) of Incident(s): Ongoing prior to October 30, 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), clauses (1) and (3): 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. · Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Summary of Findings: Pertinent information was obtained during a site visit conducted on November 6, 2025; from documentation at the facility; and through four interviews conducted with the VA’s guardian (G) who was also the VA’s family member, a facility nurse (SP1), and facility supervisory staff persons (SP2 and SP3). At the time of the site visit, the DHS investigator met the VA, but s/he declined to be interviewed. The VA’s support plans stated that in 2022 the VA moved into the facility seeking services and support relating to his/her diagnoses, which included cognitive impairment and dementia. The VA loved to sing, dance, and attend concerts and gave “really good hugs.” The facility provided at least one staff person 24 hours a day to help with the VA’s daily living tasks and medication management. The facility was a single-family house where the VA lived with three housemates, and SP2 and SP3, who were the primary caregivers. Facility documentation stated that SP1, SP2, and SP3 received training on the Reporting of Maltreatment of Vulnerable Adults Act and were a creator, reviewer, and/or trainer of the VA’s support plans. Allegation One: It was reported that the VA had multiple unexplained, “fingerprint-sized” bruises on his/her back. At the outset of the investigation, information was provided (by an anonymous person) that on October 28, 2025, the VA had “a very large amount of bruises” on the back of his/her upper arms, which were “purple and blue,” and “about the size of fingerprints.” The VA also had “yellowing bruises … the size of fingerprints,” on his/her upper back. The causes of the bruises were unknown. The VA’s support plans, including Individual Abuse Prevention Plan, stated that the VA was susceptible to abuse from others and had a history of self-injurious behaviors, like hitting him/herself. Staff were to supervise the VA, “prevent abuse,” and report concerns. The G and SP1-SP3 provided the following information: · The G and SP1-SP3 each said that they did not see fingerprint-sized bruises on the VA. The VA had a history of tripping, running into things, and “banging” his/her body parts on his/her bed railing, all of which might cause bruises. · SP1-SP3 each said that they did not engage in conduct or see other staff engage in conduct that might have caused the VA’s bruises. The VA frequently had bruises on his/her body but SP1-SP3 each believed they were caused by the VA’s own actions, and not by a staff person. The VA also had a history of rocking back and forth on a chair or toilet, which caused bruises on the VA’s back. SP3 said that as the VA’s dementia progressed, s/he became increasingly “physical” and a greater fall risk. SP1 and SP3 each said that the VA’s medications might make him/her bruise more easily. · The G said that s/he was never concerned that any of the VA’s bruises were the result of “physical abuse.” · SP1 and SP3 provided consistent information that during approximately September or October 2025, an unidentified person told SP1 that another staff person (P) “had been squeezing [the VA’s] arms too tight” and s/he had a picture of a bruise on the VA that s/he believed was caused by the P. SP1 no longer had a copy of this picture. SP1 and SP3 each said that they could not determine if the P’s conduct included squeezing the VA’s arm too tight and/or if the P’s conduct caused bruises to the VA. SP1-SP3 did not see the P engage in conduct that might have bruised the VA, and the P no longer worked at the facility. Conclusion for Allegation One: At the outset of the investigation, information was provided that the VA had multiple unexplained, “fingerprint-sized” bruises on his/her back. However, SP1-SP3 each said that they did not engage in conduct or see other staff engage in conduct that might have caused the VA’s bruises and given that the VA had a history of causing bruises to him/herself, there was not a preponderance of the evidence whether a staff person’s conduct was not an accident or therapeutic and produced physical pain or injury to the VA. 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 staff held the VA down to complete his/her cares and tied the VA to his/her wheelchair and locked the VA in his/her bedroom to prevent the VA’s “behaviors.” At the outset of the investigation, information was provided (by an anonymous person) that unidentified staff held the VA down (restrained) to complete his/her hygiene cares; and tied the VA to his/her wheelchair using a gait belt and locked the VA in his/her bedroom to prevent “behaviors.” There was no other information provided, including dates or circumstances. Regarding the VA being held down by staff to complete his/her cares: The VA’s support plans stated that staff were to help the VA with his/her activities of daily living and hygiene. The G said that s/he was not aware of staff needing to hold the VA down to complete the VA’s cares. The VA might grab and “smack” staff when they tried to help him/her get dressed, “but not the other way around.” SP1 and SP3 each said that they were not aware of staff needing to hold the VA down to complete his/her cares. The VA might initially push staff away when they were helping but would typically let staff help him/her. If staff tried to hold the VA down, the VA would likely slap the staff. SP2 said that the VA might kick at him/her when s/he tried to change the VA’s adult absorbent undergarment and so SP2 sometimes used his/her arm to block or briefly hold the VA’s leg to complete the task and prevent him/her from being kicked. However, SP2 did not hold the VA down to the bed, and this was not done in a manner that might leave a bruise or meant to intentionally bruise or restrain the VA. Regarding the VA being tied to his/her wheelchair: The VA’s support plans, including Positive Support Transition Plan, provided the following information: · The VA walked independently but might run into things or move “very slowly” and sometimes needed “considerable help” from staff with transferring into and out of chairs, bed, etc. · The VA had a history of confusion, delusions and hallucinations, and aggression towards others, like hitting and pulling hair. If the VA was unsafe toward him/herself or others, staff might manually restrain the VA. “All available restraints should be utilized to ensure safety.” · The VA’s rights were restricted to ensure his/her health, safety, and wellbeing. This included restricting the VA’s right to engage in chosen activities and have use of and free access to common areas of the facility. The “justification for the restrictions” was the VA’s diagnosis of dementia. [Note: The VA’s support plans reviewed for this investigation did not state how staff restricted the VA’s right to engage in chosen activities or access to common areas, or any information of the VA needing a wheelchair or gait belt.] The G said that s/he was not aware of staff tying the VA to his/her wheelchair. At times, staff used a gait belt to help the VA stand or transfer. SP1-SP3 provided the following information: · SP1 and SP2 each said that wheelchairs typically had a built-in seatbelt for the occupant’s safety. However, the VA’s wheelchair was an older model that did not have a seatbelt and so SP1 ordered a seatbelt for the VA’s wheelchair. The VA had “recently” started using his/her wheelchair and while they waited for the seatbelt order to arrive, staff used a gait belt to tie the VA into his/her wheelchair. The gait belt was used in the same manner and for the same purpose as a standard seatbelt. The VA could then freely maneuver his/her wheelchair around the facility, but s/he could not untie the gait belt or get out of his/her wheelchair without help. · SP3 said that “about a month ago,” the VA’s abilities had changed, and s/he had entered a “different stage” of dementia with increased physicality and confusion and decreased strength and coordination. The VA also had a history of rocking back and forth when sitting and so SP3 “implemented the safety belt” so the VA did not injure him/herself. · SP1 said that the gait belt was not used for “an extended time,” but the length of time depended on the day and how the VA was doing. SP2 said that staff used the gait belt for “a couple of days” or “a short time” until the seatbelt order arrived. SP3 said that the VA did not use his/her wheelchair very often. · SP1 added that at times the VA became “overstimulated” and might “shuffle” when walking, which caused falls. When this occurred, staff asked the VA to sit in his/her wheelchair to “calm down” and because the VA was in his/her wheelchair, staff again tied the gait belt around the VA and his/her wheelchair. The period the VA was tied to his/her wheelchair depended on what was happening and “once [the VA’s] was calm, [s/he] comes out.” SP1 did not provide specific examples of this happening and SP2 and SP3 each did not have information about the gait belt being used as a form of punishment. Regarding the VA being locked in his/her bedroom: The VA’s support plans, including Positive Support Transition Plan, provided the following information: · The VA had a history of confusion, delusions and hallucinations, and aggression toward others; and in response, staff might “guide” the VA to his/her bedroom for TV- or radio-time or to “self-soothe.” · At night, the VA struggled to sleep and “will wander.” The facility had door sensors to alert staff of movement. “When [the VA’s] medication was at a therapeutic level and [s/he] could safely and calmly move around, [s/he] could go outside or into the common areas of the facility.” The G said that the VA liked being in his/her bedroom and had a history of locking his/her bedroom door. The G was not aware of staff locking the VA’s bedroom door as a form of punishment. SP1-SP3 provided the following information: · SP1 said that the VA’s doctor recommended the VA have a “safe spot” or “safe zone,” which was the VA’s bedroom. When the VA was escalated, staff encouraged him/her to go to his/her bedroom to “calm down” and the VA would do so, but the door was never locked, and it was never for a specific length of time. The VA could leave his/her bedroom when s/he wanted to leave. · SP1-SP3 each said that the VA liked being in his/her bedroom and staff frequently encouraged the VA to hang out in the common areas more often. The VA had a history of locking his/her own bedroom door. SP1-SP3 were each not aware of staff locking the VA’s bedroom door as a form of punishment. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.06, subdivision 7, paragraph (b), states that physical contact or instructional techniques must be the least restrictive alternative possible to meet the needs of the person and may be used to facilitate the person's completion of a task or response when the person does not resist or the person's resistance is minimal in intensity and duration. Minnesota Statute 245D.06, subdivision 5, states that the license holder is prohibited from using mechanical restraints as a prohibited procedure as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, as or staff convenience. Conclusion for Allegation Two: Regarding the VA being restrained by staff to complete his/her cares: Given that there was no information regarding which staff were involved or when this occurred; that SP1-SP3 and the G did not have concerns; and that the conduct of engaging in brief physical contact with minimal intensity and duration to complete a task was consistent with Minnesota Statutes section 245D.06, subdivision 7, paragraph (b), there was not a preponderance of the evidence whether a staff person’s actions constituted an unreasonable confinement of the VA, which would be reasonably expected to cause physical pain or emotional distress. Regarding the VA being tied to his/her wheelchair: The conduct of tying the VA into his/her wheelchair was not therapeutic conduct and was inconsistent with the standards of professional caregivers in a facility licensed by the Department of Human Services, and it was a violation of Minnesota Statute 245D.06, subdivision 5. However, given that the conduct was not performed for an “extended time” and was only used until his/her seat belt order arrived or “a couple of days” or “a short time,” and was intended to minimize the VA’s risk of injuries and that the VA could still move around freely in his/her wheelchair, there was not a preponderance of the evidence whether a staff person’s actions constituted an unreasonable confinement of the VA, which would be reasonably expected to cause physical pain or emotional distress. Regarding the VA being locked in his/her bedroom: Given that there was no information regarding which staff were involved or when this occurred; that SP1-SP3 did not have concerns; and that it was documented in the VA’s support plans that staff could guide the VA to his/her bedroom when s/he was struggling as a way to calm him/her down and there was no information that this technique was misused or overused, there was not a preponderance of the evidence whether a staff person’s actions constituted an unreasonable confinement of the VA, which would be reasonably expected to cause physical pain or emotional distress. It was not determined whether an aversive or deprivation procedure 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: use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult; and use of any aversive or deprivation procedures for persons with developmental disabilities or related conditions not authorized under section 245.825). Alleged Licensing Violations: Regarding the VA’s medications and diet being changed without a doctor’s order: At the outset of the investigation, information was provided that on unspecified dates, SP2 and/or SP3 stopped administering the VA’s MiraLAX (laxative solution) and changed the VA to a “soft food diet” without consulting doctors. The VA’s support plans stated that s/he experienced constipation regularly, which staff “monitored and managed.” The VA relied on staff to prepare his/her meals, set up and administer his/her medications, and schedule and transport him/her to his/her appointments. The G and SP1-SP3 each said that the VA had a history of ongoing, intermittent constipation and there were ongoing changes to the VA’s medications, fiber supplements, and diet, which were ordered or recommended by doctors. The G was not concerned with staff changing the VA’s laxative or fiber intake or diet to help his/her ongoing constipation. Therefore, a licensing violation was not determined. Regarding the VA’s progress notes being crossed off or ripped out: At the outset of the investigation, information was provided that on unspecified dates, SP2 and/or SP3 crossed off staff documentation or ripped out pages from the VA’s progress notes. However, SP1-SP3 had no information that this occurred and without additional witnesses or details, a licensing violation was not determined. Regarding the VA’s family members being disallowed from visiting the VA: At the outset of the investigation, information was provided that on unspecified dates, SP2 and/or SP3 forbade the VA’s family members (unidentified) from visiting because they believed the visits were causing the VA’s “behaviors.” The VA’s support plans, including Positive Support Transition Plan, provided the following information: · The VA “valued” his/her family members, including the G. The VA enjoyed talking to and visiting the G. · The VA’s “indicators of a quality life,” including “family and friend visits.” Staff assisted the VA in contacting and planning visits. “Visitors are encouraged to come as often as able.” These visits helped the VA feel “comfortable” and included, and experience less agitation. If the VA was experiencing increasing agitation, staff might suggest s/he call his/her friends and family to help him/her to deescalate. SP1-SP3 each said that there were no restrictions on the VA’s visits and that staff “always encouraged [the VA’s visitors] to come.” The G said that s/he lived out of state and visited the VA, or “popped-in unannounced” at the facility, every two to three months. “I go and see [the VA] whenever I want.” Staff never told the G that s/he could not visit. However, the VA had some family members who had a history of causing the VA harm and as such, the G asked the facility to restrict those specific family members from visiting the VA. The VA was okay with this and did not ask to see those specific family members. Therefore, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The facility provided additional training to staff on the Reporting of Maltreatment of Vulnerable Adults Act, positive support strategies, “the strict prohibition of restraints,” and documentation. The VA no longer received services at the facility. Action Taken by Department of Human Services, Office of Inspector General: On May 5, 2026, the facility was issued a Correction Order for the violation outlined in this report. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that two individuals 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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