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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: 1069434-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy Minnesota Department of Human Services 651-431-2155 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP) mocked the way a vulnerable adult (VA1) spoke by imitating VA1’s nasal tone and sounds. The SP also yelled at the VAs. Allegation two: It was reported that the SP hit a vulnerable adult (VA2) in the face and leg with a frying pan, threw pens at VA2, spit on VA2, sprayed cleaner at VA2, and cut VA2’s finger with a knife. Allegation three: During the course of the investigation, it was reported that the SP smoked marijuana in the facility. Allegation four: During the course of the investigation, it was also reported that money was missing from the VAs’ petty cash accounts. Date of Incident(s): Ongoing, prior to November 3, 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 (2); and subdivision 9, 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 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. 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 November 25, 2025; from documentation at the facility; and through thirteen interviews conducted with three facility staff persons (P1 – P3), a supervisory staff person (P4), two facility health care professionals (HCP1 and HCP2), the SP, a day program staff (DPS), VA1, VA2, VA1’s guardian (G1), and VA2’s guardians (G2 and G3). Attempts were made by telephone and text to contact a staff person (P5), but P5 did not respond to the requests for an interview. Attempts were made by telephone and text to contact the SP, but after a telephone call to the SP was disconnected, the SP did not respond to additional requests for an interview. VA1 enjoyed participating in Special Olympics, bowling, volunteering, working on arts and crafts projects, fishing, and spending time with family members and friends. VA1’s diagnoses included mild developmental disabilities, bilateral hearing loss, and scoliosis. VA1 was able to read lips and used vocalizations, gestures, and American Sign Language (ASL) to communicate. VA1 went to a community job two days each week. VA1’s Individual Abuse Prevention Plan stated that the staff persons were to physically position themselves between VA1 and anyone attempting to physically abuse VA1. VA2 enjoyed going to sporting events, getting tattoos, swimming, fishing, going on community outings, and spending time with family members and friends. VA2’s diagnoses included mild to moderate developmental disability, attention-deficit hyperactivity disorder, fetal alcohol syndrome, obsessive-compulsive disorder, and profound deafness. VA1 communicated with ASL and written messages. VA2 attended a day program. VA2’s Individual Abuse Prevention Plan stated that the staff persons were to physically assist VA2 and intervene by removing VA2 away from anyone attempting to physically harm VA2. The staff persons were trained on VA2’s maladaptive behaviors and how to calm VA2 when those behaviors arose. The facility was a rambler-style building with the main living areas including the kitchen, dining room, and living room on the main level along with two bedrooms. A third bedroom and another living area were on the lower level, where a staff person provided care to a third client (C). Allegation one: It was reported that the SP mocked the way VA1 spoke by imitating VA1’s nasal tone and sounds. The SP also yelled at the VAs. VA1 stated that s/he liked living at the facility and liked his/her job. The staff persons were nice and helpful to VA1 and were not mean to him/her. None of the staff persons hit VA1, spit on VA1, or threw anything at VA1. The staff persons were “very firm” that spitting and throwing things were not allowed in the facility. The SP was kind to VA1 and VA1 was not afraid of the SP. VA1 then stated that the SP was sometimes mean, but did not yell. VA1 stated that the SP was sometimes upset while at the facility, but VA1 did not want to talk about what the SP did when s/he was upset. Sometimes the SP slept in the living room at the facility. VA2 stated that a “couple times” VA2 saw the SP sleeping in the facility’s living room and VA2 then woke the SP. P1, P2, P3, P4, HCP1, and HCP2 provided the following information: · P4 stated that most of the staff persons at the facility used ASL to communicate with the residents. P1 stated that VA1 and VA2 were each hearing impaired, but might hear loud voices or sounds. VA1 used an “exaggerated” voice to communicate. A health care professional (HCP3) told P1 that the SP occasionally used a “mocking deaf tone” when s/he talked to the VAs that seemed like the SP was “pretending to be deaf.” On one occasion, P1 heard the SP speaking to the VAs and sent a recording of the SP to HCP3. P2 stated that the SP talked the VAs “very exaggeratedly” and spoke loudly even though the VAs were deaf. P3 stated that the SP was taking an ASL class and “played into signs” more than s/he needed to and was “over the top with [his/her] signs,” which offended the other staff persons and confused the VAs. HCP2 stated that the VAs believed the SP talked to them in a condescending manner, but HCP2 believed that it was “just the way [the SP] talked” and was trying to communicate with the VAs. · P4 stated that when the SP began working at the facility, the SP took ASL classes and was “vocalizing” as s/he signed. Some of the staff persons told P4 that they found the SP’s way of speaking while signing offensive. P4 talked to the SP and told him/her that s/he should not use exaggerated vocalizing when s/he signed. P4 believed that the SP then stopped the exaggerated vocalizing when signing. Neither VA1 nor VA2 expressed concerns about the SP’s vocalizations to P4.
· P2 stated that HCP3 told P2 that s/he heard the SP yelling and swearing at the VAs and telling them that s/he “could not put up with your shit today.” HCP3 typically worked with the client on the lower level of the facility, but sometimes heard “muffled sounds” coming from the main level of the facility. VA2 often turned up the volume on the television. HCP2 stated that the SP would not know how to use sign language to say that s/he “could not put up with your shit today.” HCP2 never heard the SP make disrespectful comments to the VAs. · P3 stated that the SP spoke to VA2 loudly and P3 was uncertain if the SP believed VA2 could hear the SP if s/he spoke loudly enough. P3 stated that the SP did not “aggressively scream” at VA2, but spoke more like “telling a kid upstairs dinner is ready kind of yell.” VA2 told P3 that the SP frequently told VA2 to “stop doing things” because VA2 was not doing what the SP told him/her to do. P3 did not hear the SP say anything “mean or threatening” to the VAs. P3 stated that the SP spent a lot of time using his/her cell phone instead of interacting with the VAs. HCP1 stated that s/he typically worked with a client on the lower level of the facility and did not hear or see anything that occurred on the main level of the facility that concerned him/her. · P3 stated that the SP had a hard time working with VA2 because s/he was unable to communicate with him/her since the SP did not know ASL. The SP and VA2 became frustrated with each other because of their inability to communicate with each other. At times, VA2 would become upset and have behaviors like setting off the fire alarm, becoming aggressive, destroying his/her bedroom, or hitting the staff persons. P3 sometimes had to help the SP with administering medications or assisting VA2 with cares. HCP2 stated that the SP expected the VAs to follow the rules, which upset VA1 and VA2. HCP2 never saw the SP being mean to the VAs. · P2 stated that when the SP arrived at the facility for his/her work shift, VA1 typically went to his/her bedroom because s/he did not want to be around the SP. HCP2 stated that VA1 typically spent little time socializing and often spent time alone in his/her bedroom, but came out for meals. When VA2 was angry, VA1 went to his/her bedroom. · P1 stated that s/he saw the SP sleeping at the facility during his/her work shift. On one occasion, P1 was working on the lower level of the facility and heard the oven timer in the kitchen on the main level “beeping” for several minutes so P1 went upstairs. The SP was sleeping in a chair in the living room and had not been awakened by the oven timer even though s/he was only a few feet from the oven. P1 deliberately made loud noises in the kitchen, but the SP did not wake until VA1 and VA2 entered the living room from their bedrooms. P3 did not see the SP sleep at the facility, but saw the SP being tired and inattentive to the clients. P4 stated that on one occasion, a staff person told P4 that s/he saw the SP sitting on the sofa with his/her head in his/her hands and believed the SP was sleeping. P4 talked to the SP who told P4 that s/he was resting his/her eyes at the end of his/her work shift. P4 did not understand why a staff person would allow another staff person to sleep for extended periods of time and not tell P4 about it. P4 also believed that VA2 would tell him/her if a staff person slept during his/her work shift. · P1 believed that VA1 and VA2 were generally accurate reporters of events. P3 believed that VA1 was a “pretty accurate” reporter of events, but that VA2 might “embellish things,” especially about a staff person that s/he did not like. G1 stated that VA1 preferred to be alone rather than spend time with the other clients and staff persons. VA1 liked to watch television in his/her bedroom. VA1 was always happy at the facility and had not complained about anything at the facility. VA1 was an accurate reporter of events, but could be “manipulating” about food. G1 had no concerns about the care VA1 received at the facility and VA1 did not tell G1 about any concerning incidents. Facility documentation showed that the SP, P1, P2, P3, P4, HCP1, and HCP2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on VA1’s and VA2’s plans prior to the incidents. Conclusion for allegation one: After the SP began working at the facility, s/he took ASL classes so that s/he could communicate with VA1 and VA2, who were deaf. Information was provided that when the SP then used ASL with the VAs s/he also spoke to the VAs “very exaggeratedly” and “played into signs” more than s/he needed to and was “over the top with [his/her] signs,” which offended the other staff persons and confused the VAs. P4 stated that after s/he learned of the concerns with the SP’s communications with the VAs, s/he talked to the SP and explained that s/he should not use exaggerated vocalizing when s/he signed. P4 believed that the SP then stopped the exaggerated vocalizing when signing. Neither VA1 nor VA2 expressed concerns about the SP’s vocalizations to P4. P2 stated that HCP3 told P2 that s/he heard the SP yelling and swearing at the VAs, but while some of the other staff persons stated that the SP sometimes spoke loudly to the VAs, no additional information was provided that s/he swore or yelled at the VAs. Although information was provided that VA1 went to his/her bedroom when the SP worked at the facility, VA1 stated that the SP was kind to VA1 and s/he was not afraid of the SP. Additional information was provided that VA1 typically spent much of his/her time in his/her bedroom. Information was provided that the SP sometimes slept while at the facility, which was against the facility’s policies. P4 talked to the SP about sleeping at the facility and the SP told him/her that s/he was only resting his/her eyes at the end of his/her work shift. VA2 stated that on one occasion s/he saw the SP sleeping and then woke the SP. Although the SP might have used exaggerated and loud vocalizations when s/he began using ASL to communicate with the VAs, it was unclear if the SP used the vocalizations in a mocking manner or if s/he believed the vocalizations were necessary when using ASL. After P4 talked to the SP about using the vocalizations, the SP stopped vocalizing in such an exaggerated manner. Given the above information about the SP’s vocalizations; the inconsistent information provided about the SP yelling and swearing at the VAs; and that the VAs expressed no concerns about the SP’s interactions with them, there was not a preponderance of the evidence whether the SP’s actions could reasonably be expected to produce physical pain or injury or emotional distress to VA1 and VA2. 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, or threatening). Allegation two: It was reported that the SP hit VA2 in the face and leg with a frying pan, threw pens at VA2, spit on VA2, sprayed cleaner at VA2, and cut VA2’s finger with a knife. VA1 stated that the SP sometimes yelled at VA2 when VA2 became upset and it was “not good.” VA2 stated that the SP was “crabby,” threw pens and pencils at VA2, and “smacked” VA2 on the back. The SP hit VA2 with a cooking pan on the leg and in the face. The previous week, the SP sprayed cleaning liquids at VA2. The SP cut VA2’s finger with a knife, which is why VA2 had a bandage on his/her finger. Although VA2 could read lips, s/he could only understand “a little bit” of what the SP said. VA2 did not like the SP. P1, P2, P3, P4, HCP1, and HCP2 provided the following information: · VA2 told P2 that the SP chased VA2 around the facility while holding a pan. VA2 told P2 it was “really scary.” P3 stated that VA2 told the staff persons that the SP hit VA2 with a pan, but a few weeks later, VA2 had an interdisciplinary team meeting and told them that s/he hit the SP with a pan because s/he did not like the SP because s/he did not understand VA2 when s/he used sign language. The staff persons did not see any injury to VA2. None of the staff persons saw the SP hit VA2 with a pan. · HCP2 stated that on one occasion s/he was working on the lower level of the facility and heard something being thrown on the main level. When s/he went upstairs, the SP was sitting at the table and saying that s/he should not be “abused.” VA2 was “red faced” and pots and pans were spread on the floor, as well as the SP’s books, pens, and papers. VA2 told HCP2 that s/he was mad at the SP and did not like him/her. HCP2 believed that VA2 threw the items around because s/he wanted to “be seen and heard” and the SP refused to take VA2 to the store to purchase a newspaper even though it was late at night. VA2 had a history of taking utensils from the kitchen and threatening the staff persons with them. If VA2 believed s/he would get in trouble for doing something, s/he would claim that another person did it. P4 talked to VA2, who told P4 that s/he hit the SP with a pan, but did not say that the SP hit VA2. · P2 stated that the SP threw shoes at VA2’s leg when s/he sat on the sofa watching television. P3 stated that VA2 threw clothing at the SP when VA2 did not want to fold his/her clothing. P3 stated that on one occasion, VA2 told P3 that a staff person sprayed cleanser on VA2’s face, but s/he did not provide the name of the staff person who sprayed him/her. P4 stated that none of the staff persons or VAs brought concerns to him/her about any staff person spraying disinfectant around the VAs. · P3 stated that VA2 told the staff persons that the SP pricked VA2’s finger for blood sugar testing, which was not part of VA2’s cares, but VA2 had a mark on his/her finger that did not typically result from a needle poke. Prior to VA2 reporting that the SP cut his/her finger, VA2 had cut his/her finger when taking off a pop can tab. P4 stated that VA2 told him/her that s/he cut his/her finger on a pop can. HCP2 stated that on one occasion VA2 got a paper cut at work, but told the staff persons that s/he was bitten by a snake in the garden. P4 stated that VA2 would tell him/her about any injury or bruise that s/he had. · P4 stated that VA2 preferred going on community outings and going to stores rather than completing his/her chores at the facility. VA2 told P4 that s/he did not like the SP, but could not tell P4 why s/he did not like the SP. P3 stated that VA2 would “do what [s/he] can to get [a staff person] fired” if s/he did not like them. HCP2 believed that VA2 sometimes exaggerated when talking about what occurred and sometimes began to believe things were factual after s/he repeated them. P4 stated that VA2 tended to make up stories if s/he did not like someone and did not always get the facts straight. None of the staff persons brought concerns to P4 about the SP becoming “physical” with the VAs. P4 believed the SP interacted well with VA2 and got VA2 what s/he needed. The DPS stated that on an unknown date, while VA2 was at his/her day program, VA cut his/her finger when s/he pulled a tab off a pop can. A bandage was placed on VA2’s finger and the facility was told about the incident. G2 and G3 stated that VA2 had not made any complaints to them about the staff persons. VA2 was typically a reliable reporter of events, but might make up “funny stories” to get attention. If someone harmed VA2, s/he would tell someone about the incident. Conclusion for allegation two: Although VA2 provided information that the SP hit him/her with a pan, VA2 later stated that s/he hit the SP with a pan because s/he did not like the SP because the SP did not understand VA2 when s/he used sign language. The staff persons did not see any injury to VA2. None of the staff persons saw the SP hit VA2 with a pan. VA2 told the staff persons that the SP sprayed disinfectant on him/her, but no further information was provided about the incident. On one occasion, VA2 stated that the SP cut VA2’s finger, but information was provided that at that time VA2 cut his/her finger on a pop can tab. VA2 told P4 that s/he did not like the SP, but was unable to provide information about the reasons for his/her dislike. Given that VA2 provided inconsistent information and that none of the staff persons corroborated that the SP hit VA2 with a pan, sprayed disinfectant at VA2, or cut VA2’s finger, there was not a preponderance of the evidence whether the SP’s action produced or could reasonably be expected to produce physical pain or injury or emotional distress to VA2. 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 three: During the course of the investigation, it was reported that the SP smoked marijuana in the facility. VA1 stated that s/he saw the SP use his/her vape in the facility and it was “not good.” VA1 also saw the SP place a marijuana cigarette on the table and later smoke the cigarette inside the facility. After smoking the marijuana, the SP drove home alone. VA2 stated that the SP sometimes smoked a vape in the facility. P1, P2, P3, P4, HCP1, and HCP2 provided the following information: · P1 stated that in the past, s/he saw vape pens and “pre-rolled packages” on the facility’s front entry table and “was certain” s/he smelled marijuana in the facility, but did not see marijuana. P1 told P4 about it, but “nothing came of it.” P3 stated that s/he smelled marijuana in the facility, but did not see the SP smoke marijuana in the facility. On one occasion when the SP was working at the facility, P3 and P1 saw a vape, “raw cones,” and a lighter on a table where the VAs could access them. P3 stated that the SP “seemed out of it” and sprayed Febreze air freshener “all over the house.” On one occasion, HCP3 sent P1 a photograph of cigarette papers sitting on a table in the facility. P2 stated that the facility sometimes smelled like marijuana smoke after the SP worked at the facility. · HCP2 stated that s/he sometimes smelled cigarette smoking “wafting in” the windows from the back porch, but never smelled marijuana in the facility. HCP2 heard that in the past, prior to the SP working at the facility, marijuana and alcoholic beverages were found in the facility and in the facility’s van. · P4 stated that on one occasion, a staff person told him/her that there were cigarette papers on a table in the facility and there was a smell of marijuana in the facility, so P4 went to the facility and told the SP that s/he could not leave the papers where a VA could access them. P4 stated that the facility did not smell like marijuana on that occasion or at any other time when P4 was at the facility. The facility’s Policy and Procedure on Alcohol and Drug Use stated that the staff persons were not allowed to work, transport a client, drive on company business, or accompany a client into the community when under the influence of alcohol or illegal drugs or impaired by any chemicals or prescription or legal drugs. Conclusion for allegation three: While VA1 stated that the SP smoked a marijuana cigarette, none of the staff persons saw the SP smoking marijuana at the facility and it was unclear if items left on a table at the facility were used for smoking or vaping regular tobacco or marijuana. Given that no additional information was provided that the SP smoked marijuana at the facility or drove the VAs in the community after using marijuana, there was not a preponderance of the evidence whether there was a failure to provide the VAs with care or supervision which was reasonable and necessary to maintain the VAs’ physical or mental health or 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). Allegation four: During the course of the investigation, it was also reported that money was missing from the VAs’ petty cash accounts. VA1 stated that sometimes the staff persons borrowed VA1’s money, but later returned it to VA1. VA1 did not provide additional information about his/her money. P1, P2, P3, P4, HCP1, and HCP2 provided the following information: · P1 stated that s/he was told by other staff persons that the VAs’ financial records and cash accounts “were all screwed up.” P1 believed that the supervisory staff persons “tracked it down.” · P3 stated that at times there were no receipts for the VAs’ purchases or correct documentation about the purchases. P3 believed that the SP attempted to take charge of the VAs’ petty cash files because there was so much missing information, but the SP did it “all wrong” and “messed up” the records. P3 believed that the records were finally done correctly and the accounts were “only a couple of cents short.” · HCP2 stated that VA2 recently told HCP2 that s/he had “extra money” that one of the staff persons gave to VA2. VA2 did not provide additional information about who gave money to VA2 or how much money s/he was given. HCP2 stated that some of the staff persons allowed VA2 to keep the change when s/he made purchases, but other staff persons did not. HCP2 believed that the staff persons did not always keep receipts for purchases made by the VAs. P4 stated that VA2 liked to purchase items, but did not have an understanding about how much items cost. · P4 stated that the VAs’ petty cash accounts were regularly checked and balanced after every transaction the VAs made. P4 would know if the accounts did not balance. There might be an occasional time when the accounts were off by a few cents, but there were no other discrepancies. G1 stated that VA1 did not handle his/her money and the staff persons used VA1’s cash to make purchases for VA1. VA1 “doesn’t want to spend money” and G1 often purchased items for VA1. VA1’s money was kept in P4’s office and the staff persons requested money from P4 when they needed to purchase items for VA1. G2 and G3 stated that the staff persons gave VA2 money for community outings and then returned any change to VA2’s petty cash fund. G2 and G3 received regular reports about VA2’s petty cash fund and his/her spending. They had no concerns about VA2’s finances. Conclusion for allegation four: Although it was reported that money was missing from the VAs petty cash accounts, no information was provided that the SP took money from the VAs’ accounts or that money was missing from the petty cash accounts. Given that no information was provided that any money was missing from the VAs’ petty cash accounts or that the SP took money from the VAs, there was not a preponderance of the evidence that in the absence of legal authority the SP willfully used or disposed of the VAs’ funds 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 an internal review and determined that the facility’s policies and procedures were adequate and were followed. While the facility determined that there was not a need for additional training or corrective action, plans and procedures were reviewed with the SP. 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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