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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: 1108638-HCBS (Home and Community-Based Services) Investigator(s): Gessner Rivas/Beth Virden Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) told a staff person (SP) to leave the VA’s apartment, the SP refused to leave and punched the VA’s face. Date of Incident(s): February 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 subdivision2, 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 11, 2026; from documentation at the facility and law enforcement records; and through five interviews conducted with the VA, the VA’s guardian (G) who was also the VA’s family member, the VA’s case manager (CM), a facility staff person (P), and a supervisory staff person (SP). The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA’s diagnoses included traumatic brain injury. · In September 2025, the VA began receiving integrated community services (ICS) from the facility. The facility provided the VA with one staff person ten hours per day seven days a week. The staff person helped the VA with administering medications, cleaning, cooking, budgeting, and shopping. · The VA was a social person who enjoyed spending time with his/her family and friends. The VA was able to communicate his/her wants and needs and advocate for him/herself. · At times, the VA might become frustrated and swear or yell. Staff were to talk to the VA in a “calm voice,” and if the VA remained escalated, staff were to give the VA space and check in with him/her later. The VA lived by him/herself in an apartment, which is also referred to as the facility throughout this report and which shared a building with 11 other apartments. The license holder did not own the building but leased three of the apartments and then subleased these three apartments to clients, like the VA. [Note: The apartments where the license holder provided services were “provider-controlled” ICS settings. An ICS setting was a setting in which the license holder had an approved setting capacity report and had direct/indirect control over a person’s living unit (e.g., apartment), which meant that the license holder either owned, operated, or leased the living unit, or had direct or indirect financial interest in the property or housing, including a financial relationship with the property owner.] Law enforcement records provided the following information: · On February 12, 2026, at 5:20 p.m., 9-1-1 dispatch received a call from an unidentified person reporting an assault at the facility. Law enforcement officers (LEO) arrived and spoke with the SP, the P, and the VA. · The SP told the LEO that around 2 p.m., s/he entered the VA’s apartment to relieve the staff person, who had been working with the VA since the morning. The VA was asleep at that time. At 5 p.m., the P entered the VA’s apartment to relieve the SP. The SP and the P chatted about the VA’s day as part of their shift change and information sharing. However, the VA woke up and yelled at the SP to leave his/her apartment. The VA walked toward the SP and the SP moved a chair between them and told the VA, “Stop.” The VA punched the SP’s face, grabbed the SP’s neck, and pushed the SP backwards out of the apartment and into the hallway. The P left the apartment and the VA closed and locked the door. · The LEO took photographs which showed small red marks on the SP’s neck and red scratches on either side of the SP’s face and forehead, which the SP said that s/he sustained during the incident. · The P told the LEO that every day staff entered the VA’s apartment for shift change. The VA told the SP to leave and then hit the SP with closed fist punches for a few minutes until the SP got away and someone called 9-1-1. · The LEO met the VA who was lying on the floor in his/her bedroom. The VA appeared to be “manic” and “under the influence of some type of mood-altering drug.” The VA told the LEO that the SP grabbed the VA’s neck and shirt, and that the VA pushed the SP into the hallway but did not hit the SP. · The LEO issued a citation to the VA for assault and transported him/her to a hospital for a mental health evaluation. The law enforcement case was closed. The VA told the DHS investigator that the SP should have knocked before entering his/her apartment and that when the VA told the SP to leave, the SP said that s/he did not have to leave because it was the facility’s apartment. The SP punched the left side of the VA’s cheek and mouth, and the VA punched the left side of the SP’s head. The SP left the VA’s apartment, and the VA called 9-1-1. The VA did not sustain injuries. The G and the CM each said that they each saw the VA at some point after the incident and did not see injuries on the VA. The VA told the G and the CM what happened which was consistent with what the VA told the LEO and the DHS investigator. The CM said that the VA did not have a history of providing “false reports.” The SP and the P each provided information to the DHS investigator, which was consistent with what they told the LEO. The SP added that the VA’s prescheduled ICS hours were between 9:30 or 10 a.m. and 8 p.m., or between 12 noon and 10 p.m. The SP said that s/he did not hit the VA and did not refuse to leave the VA’s apartment or state that the apartment belonged to the facility. The SP was packing his/her things to leave when the VA hit him/her. The P said that s/he did not see the SP hit the VA but saw the VA hitting the SP. The SP tried to get away, pushed the VA back, and blocked the VA’s fists. The SP was “defending [him/herself]” and “was not physical with” the VA. The VA’s Updated Sublease Agreement with the facility provided information about the rent amount, security deposit, responsibility for repairs, etc. There was no information regarding staff entering the VA’s apartment. Minnesota Statutes section 245D.04 and the facility’s Service Recipient Rights policy each stated that all clients had the right to: · Have personal privacy, including using a lock on the person’s bedroom door. · Choose the person's visitors and time of visits. · Exercise these rights personally without retaliation. During this investigation, concern was also raised about the amount of the VA’s utility bills. However, after reviewing records, the VA’s bill was high for one month because the utilities company charged the VA, then reimbursed the VA, and then charged the VA again for two months combined. There was inadequate information to state what exactly happened or why. Facility documentation stated that the SP received training on the VA’s support plans, including Individual Abuse Prevention Plan. However, the SP did not receive annual training on the Reporting of Maltreatment of Vulnerable Adults Act as required, which was a violation of Minnesota Statutes 245D.09, subdivision 5, which states that the license holder must provide annual training to staff on their responsibilities related to protecting persons from maltreatment and reporting maltreatment. Conclusion: Consistent information was provided that on February 12, 2026, the VA told the SP to leave his/her apartment, and at some point, the SP and the P left the VA’s apartment. Although the VA said that the SP should have knocked before entering, it was reasonable for the SP to enter given that it was during the VA’s prescheduled ICS hours and that there was already a staff person present in the VA’s apartment who needed to be relieved. It was also unclear how quickly the SP left, or how much time passed between when the VA told the SP to leave and when the SP left. The P arrived at 5 p.m. and the SP and the P chatted about shift change, and then the VA told the SP to leave and someone called 9-1-1 at 5:20 p.m. Given this, there was inadequate information to determine whether all the SP’s actions were consistent with Minnesota Statutes section 245D.04 and the facility’s Service Recipient Rights policy or whether there was a violation. In addition, the SP and the VA each told the LEO and the DHS investigator that they were assaulted by the other. The SP had injuries on his/her face, and the VA did not have injuries. The P did not see the SP hit the VA but saw the VA hit the SP. The CM said that the VA did not have a history of providing inaccurate information, and the VA provided consistent information when recalling the incident. Given that the SP’s account and the VA’s account were each supported to some degree, it was not determined whose account was more credible. Therefore, there was not a preponderance of the evidence whether the SP’s conduct was not an accident or therapeutic and produced or could reasonably be expected to produce 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were followed. However, the VA’s history of assaultive behavior was inadequately documented in the VA’s support plans, which were since updated. The VA had exhibited a pattern of verbal aggression and escalating behaviors and substance use. Action Taken by Department of Human Services, Office of Inspector General: On May 6, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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