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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: 1104918-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Deb.Neubauer-Hoffman@state.mn.us 651-431-6567 Suspected Maltreatment Reported: It was reported that unidentified staff persons neglected a vulnerable adult’s (VA’s) hygiene. On multiple occasions the VA arrived at school with dirty, stained clothing that was worn the previous day, his/her face was not washed as food was visible, his/her teeth were not brushed, and his/her fingernails were not trimmed. Date of Incident(s): March 31, 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 17, paragraph (a): 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 April 22, 2026; from documentation at the facility; and through seven interviews conducted with three facility staff persons (P1-P3), a guardian (G), and three school staff persons (S1-S3). An attempt was made via email to obtain information from a case manager (CM); however, s/he did not respond. This investigator met the VA, who was eating breakfast (pepperoni and hot Cheetos), and s/he did not provide information pertinent to this investigation. The VA had 1:1 staffing at the facility and in the community. The VA enjoyed shopping and going on car rides. The VA’s favorite foods were hot Cheetos, hotdogs, peanut butter cups, and pepperoni. The VA’s diagnoses included disruptive mood dysregulation disorder, attention deficit hyperactivity disorder, autism, and prediabetes. The VA’s bedroom was located downstairs at the facility. The VA’s Self-Management Assessment (SMA) stated that s/he understood where to put his/her clean and dirty clothes and that staff persons assisted him/her with doing laundry. The VA did “very well” with staff persons assisting him/her with brushing his/her teeth, washing his/her face and shaving. The VA needed assistance with cutting his/her finger and toenails. The VA was a “very picky eater” and was encouraged to try new foods. To assist with proper nutrition, the VA was provided Ensure with every meal. The Department of Human Services received information that on March 31, 2026, the G was informed that the VA arrived at his/her school wearing the “same clothes” as the previous day. The VA’s clothing was “very dirty” with “several stains” and his/her face was not washed. These were ongoing concerns that were addressed with the facility via email “several times” and through virtual team meetings. On February 27, 2026, a county licensor (CL) issued a Correction Order to the facility for not assisting the VA with nail trimming and teeth brushing and for the VA arriving at school not wearing proper clothing for the weather and/or wearing clothing worn the previous day with food and other debris observed on the clothing. The facility’s response was that staff persons were retrained, and expectations were reviewed. The facility had two levels and served two individuals (the VA and one other client). The main level of the facility consisted of a kitchen, living room, dining room, bathroom, bedroom, an office, and a sensory room. The second bedroom was on the lower level along with a bathroom, laundry/utility room. S1-S3 each worked at the school that the VA attended and provided the following information: · S1 said that s/he was aware of documentation from March 31, 2026, when the VA came to school with “dirty, stained clothes worn the previous day and food on [his/her] face.” S1 said on two occasions school staff persons assisted the VA with nail clipping. · According to S2, the VA “uses [his/her] shirt as a napkin” resulting in food on his/her shirts. The VA “loved hot Cheetos” and that food was observed on his/her shirt and teeth. S2 believed this occurred “on average once every other week.” S2 located two emails that notified the G of concerns about the VA’s appearance at school. The first was on January 7, 2026, when the VA came to school with dirty clothes, teeth not brushed, and long fingernails. The second was on February 3, 2026, when the VA came to school with long fingernails, two sweatshirts but no hat or jacket in five-degree weather, and his/her teeth were not brushed. The facility brought the VA’s jacket to school later that day. The VA was not aggressive when attempts were made to assist with hygiene. S2 was not aware of any harm that resulted from the VA’s clothing or hygiene appearance. · S3 said that “pretty often” the VA came to school in the same clothes s/he wore the day before and the shirts were “filthy” with food. On one occasion the food on the VA’s shirt was “white and crusty.” The VA also came without his/her teeth brushed and Cheetos were seen on his/her mouth and lips. On one day the VA said that his/her teeth hurt and a toothbrush was given to the VA to brush at school. S3 believed the VA came to school without a winter jacket “two or three times” and S2 followed up with the facility. S3 was not aware of any harm resulting from the VA’s clothing or hygiene appearance. The G said that the VA had “plenty of clothes” so there was no reason the VA had to wear the same or dirty clothes for two days. Regardless, the G was told the VA arrived at school in with poor hygiene “a few times.” Meetings were held with the facility, and the G and the CM were told it would “not happen again.” The G came to the facility every weekend and was concerned that staff persons were not “engaging,” or were “disinterested” with the VA because the G observed unidentified staff persons “lounging around” with hats over their faces and “appeared to be napping” or were on their cell phones while the VA was alone in his/her bedroom downstairs. The G described the staff persons as “present but not engaged.” P1 provided the following information: · The VA required “a lot of assistance and redirection with daily cares;” however, s/he was able to do many things him/herself if “coached.” The VA’s morning routine once s/he was awake, was to get dressed, brush his/her teeth, and then come upstairs to drink Ensure and eat breakfast, often consisting of pepperoni and hot Cheetos. The food the VA ate in the morning was “messy” because the VA ate with his/her fingers and wiped them on his/her shirt. · The VA’s clean clothes were kept in his/her bedroom, with socks in drawers beneath his/her bed and pants and shirts in a closet. With verbal cues to get dressed, the VA picked out what s/he wanted to wear. There was a basket in the VA’s room for dirty clothes. P1 believed the VA’s nails were trimmed once a week; however, P1 “did not do that part.” · P1 said that s/he received an email “once or twice” about the VA going to school in the same or dirty clothes. P1 believed s/he worked on both days in question and said in the morning the VA gets “fixated” on the bus or van, was not a fast eater, and took up to 45 minutes to eat in the morning, often eating until s/he went out the door. The time the VA wore the same clothes two days in a row, P1 said that the VA’s clothes were laundered the night before and were clean; however, P1 did not realize the VA wore the same clothes the day before. That morning, the VA wanted ice cream for breakfast, and it melted onto his/her shirt. The van arrived to transport the VA and his/her shirt was not changed. · P1 was not aware of any harm to the VA that resulted from the concerns with clothing, teeth brushing, or nail clipping. P2 provided similar information to P1 regarding the VA’s morning routine. Although the schedule showed that P2 worked on March 31, 2026, (a day one of the emails was sent regarding stained clothing worn the day before), P2 was not aware if the VA wore the same clothes as the day before and “nothing stood out” as far as the VA having food on his/her clothing before leaving for school. Sometimes the VA was dressed before P2 arrived for work in the morning and if P2 was not sure the VA’s teeth were brushed before coming upstairs for breakfast, P2 prompted the VA to do so. P2 said s/he did not always go downstairs to “watch” the VA brush his/her teeth. Regarding the VA’s nails, P2 was not aware of any “protocol;” however, P1 recently told P2 to have staff persons document when the VA’s fingernails were cut or checked. P2 was not aware of anything in place to prompt staff persons to check the VA’s toenails. After a meeting on April 22, 2026, P2 was told the VA might need to be asked to change his/her clothing after eating breakfast if s/he wiped his/her hands on his/her shirt. However, P2 believed it would be “hard” because the VA needed “a lot of time” to eat and usually ate until the van arrived to transport him/her to school.
P3 said that the VA was “rarely” up before the 8 a.m. staff person arrived. Once awake the VA dressed and brushed his/her teeth, then came upstairs to eat breakfast until his/her van arrived. The VA was a “muncher” and required “a lot” of redirection to sit at the table because s/he took “breaks” while eating and went to the sensory room. P3 said they could try to “avoid Cheetos” but that was one of the VA’s favorite foods and it would be “chaos” to change the VA’s clothes before leaving for school because s/he would continue to eat and put his/her hands on the clean clothing. The VA had “preferred” clothing and it was possible for him/her to wear the same clothing the day after it was laundered. The VA was “compliant” with assistance with brushing his/her teeth and when s/he saw a dentist there were no concerns with the VA’s teeth. P3 believed that the VA’s finger and toenails were made a “Sunday routine” for the VA after the CL issued the Correction Order on February 27, 2026. Documentation showed the VA went to the dentist on February 7, 2025, however, the VA “would not open [his/her] mouth.” The dentist suggested the VA return in six months. The VA returned to the dentist three months later (May 29, 2025) and was seen for a “check up for tooth pain.” The VA’s teeth were cleaned, and no additional dental work was identified. The VA returned to the dentist on March 13, 2026, and his/her teeth were again cleaned, and no additional dental work was identified. Facility information showed that staff persons were trained regarding the VA’s program plans, service documentation, person-centered thinking, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information showed that the facility received information that school staff persons were concerned about the VA coming to school with dirty clothing, the same clothing as the day before, teeth not brushed, and/or fingernails not clipped. The VA’s SMA showed that s/he did “very well” with staff persons assisting him/her with brushing teeth, washing his/her face, and stated that s/he needed assistance with trimming his/her fingers and toenails. Regarding the VA’s clothing: S1-S3 stated the VA came to school with dirty and/or the same clothing as the day before more frequently than was reported to the facility. S2 estimated the VA arrived with dirty clothes “once every other week.” P1-P3 provided information that the VA wore clean clothes daily; however, the VA chose his/her own clothes each morning and it was possible that after his/her clothing was washed, s/he chose the same clothes as the prior day. Since the VA ate with his/her fingers and wiped his/her hands on his/her clothing, the clothing that started off as clean may have been soiled during breakfast given s/he was a picky eater and chose specific items such as hot Cheetos, pepperoni, or ice cream, all of which would be visible if s/he wiped his/her hands on his/her clothing. Given the VA was a slow eater and ate until the van arrived to transport him/her to school, changing the VA’s clothing before leaving was not attempted. Regarding the VA’s teeth being brushed: S2 and S3 were concerned that the VA’s teeth looked as if they were not brushed prior to arriving at school and on one occasion the VA mentioned his/her teeth hurt. P1-P3 each stated the VA brushed his/her teeth daily, prior to eating breakfast because that was his/her routine. Documentation showed that the VA went to the dentist three times between February 2025 and March 2026 and no dental issues were identified. Regarding the VA’s nails being trimmed: S1 and S2 said that the VA came to school with long fingernails that were then trimmed by school staff persons on two occasions. In February 2025, the CL issued a Correction Order for the facility not assisting the VA with nail trimming. P1-P3 provided inconsistent information regarding when the VA’s nails were checked, who was responsible, and/or how or if completion would be documented. Regardless, there was no information that there was harm to the VA nor that his/her health was affected. Although there were concerns regarding the cleanliness and care of the VA’s overall hygiene, given that the VA’s teeth were brushed and s/he started with clean clothes daily and s/he did not have any health issues or apparent harm regarding his/her clothing, nails, and teeth, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to maintain his/her health. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and were followed. The facility planned to have wet wipes available near the door so the VA’s hands and face could be cleaned prior to leaving, and the facility would send additional clothing to school in the event the VA needed to change upon arrival. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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