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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: 1070624 -H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas gessner.rivas@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP1) called a vulnerable adult (VA) a ”fat bastard,” and yelled at the VA and that another staff person (SP2) “agreed” with SP1. It was also reported that unknown staff persons have yelled at the VA causing the VA to become overwhelmed and engage in acts of self-harm, and that a facility resident (R) teased the VA. Date of Incident(s): August 29, 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), clause (2): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 11, 2025; from documentation at the facility; and through five interviews conducted with SP1, a facility supervisor (P1), the R, the VA, and the VA’s guardian (G). SP2 did not respond to requests for an interview. The VA was diagnosed with a mild intellectual disability, major depression, and obsessive-compulsive disorder. The VA enjoyed going out into the community, watching TV, and journaling. The VA lived in rural setting facility surrounded by farmland with a state highway a short walking distance to the east of the facility. The facility was an unlocked facility. The VA’s Individual Abuse Prevention Plan (IAPP) noted that the VA had a history of leaving the facility without permission when upset or angry, including heading toward the nearby highway. In such instances staff persons were to follow if possible. The facility’s Incident Report stated that on August 29, 2025, the VA was upset and went to a barn on the facility property with a backpack and then started walking down the facility driveway toward a road. SP1 followed and attempted to get the VA to go back to the facility but the VA ignored SP1. SP2, who remained in the facility, called law enforcement once SP1 and the VA were out of SP2’s sight. Law enforcement arrived and the VA was transported to the hospital for mental health evaluation. The VA provided the following information: · The VA could not provide specific dates or names but alleged that staff persons (the VA was not able to recall who or how many staff persons) would yell at her/him; saying that s/he did not know how to do this or that, making the VA feel “threatened.” The VA would tell staff persons not to yell or cuss at her/him, but staff persons would reply by telling the VA s/he was “full of shit.” The VA stated that this also occurred on the date of the incident when s/he tried to walk onto the highway and it was the same staff person that allegedly called the VA a “fat bastard.” The VA did not recall if anyone else was around when this happened and did not know the day it happened; the VA stated that the staff person yelled at her/him in the barn. (Investigator’s note: Although the VA did not name SP1, information showed that the VA was likely referring to SP1.) · The VA recalled that there was a staff person grilling burgers or hot dogs and that it was the same person that called her/him “fat bastard,” and yelled at her/him the day of the incident. · The VA recalled that a staff person was “rubbing it in,” about her/his girl/boyfriend and it made the VA mad because the VA had broken up with her/him and was struggling because of it. The VA stated that s/he sometimes wanted to leave the facility because s/he did not like getting yelled at and did not like everybody, particularly the R, “rubbing it in,” who would also tell the VA that s/he did not know how to do this or that. This caused the VA to have suicidal thoughts. · The VA stated that s/he mostly got along with SP2 but sometimes SP2 would get aggressive. The VA recalled an incident in which SP2 “snapped” at the VA because s/he asked SP2 what SP2 had said. The VA did not provide further details about this. SP1 provided the following information: · On August 29, 2025, when SP1 arrived at the facility, P1 had been talking to the VA, then the VA wrote for a while the SP1 prepared to grill some brats. Around 4:15 p.m. the VA went down to the barn and SP1 asked the VA what s/he was doing, but the VA did not want to talk. SP2 went down to the barn to talk to the VA but the VA did not want to talk, so SP2 returned to the facility. · SP1 went down to the barn, the VA said s/he was waiting for the storm to pass because it was “sprinkling,” and then said s/he did not want to talk. As SP1 returned to the facility, the VA began to walk away, SP1 began to follow the VA and tried talking the VA out of leaving but the VA did not want to talk. The VA began to walk along the road and SP1 called SP2 who was in the facility to call law enforcement called because the VA would not stop. The VA had gotten to a highway exit ramp when law enforcement arrived. · SP1 denied ever calling the VA a “fat bastard,” or anything like that. · SP1 noted that sometimes when the VA was writing on the computer, the VA would verbalize what s/he was writing and SP1 would hear the VA say things about harming her/himself or others. P1 provided the following information: · On August 29, 2025, in the afternoon, the VA journaled on her/his computer about an ex-partner that had ended the relationship and about leaving the facility; the VA typically wrote about things that frustrated her/him. · After the incident, P1 spoke with SP1 about it and SP1 told P1 that s/he tried to talk to the VA, but the VA refused as s/he packed a bag and the VA went to the barn. The VA waited in the barn as it had started to rain and told SP1 that as soon as it stopped raining, s/he was going to leave, which the VA did and SP1 followed the VA down the driveway and toward the highway, but the VA refused to talk to SP1. The VA refused to return to the facility, so law enforcement was called, and the VA went to a hospital. · The VA had on previous occasions talked about running out onto the highway and on one occasion P1 stood in front of the VA to prevent her/him and the VA said, “I’m not coming back to the fucking house, I fucking hate you bunch.” · On one occasion P1 stopped the VA from going out on the highway because the VA was talking about running onto the highway. The VA would often make comments about hurting her/himself. · P1 stated that the VA had never alleged that a staff person called the VA by any name; the VA tended to provide inaccurate information and exaggerate the truth. The VA would tell others that s/he was fired from work, when it was only a service interruption. · P1 stated that the VA got along with SP1, the VA used to talk to SP1 who would always help the VA work through things. P1 had never heard SP1 call any resident by any names. P1 had no concerns regarding SP2. The R lived at the facility for about six years. The R recalled the events of August 29, 2025; the VA was upset because her/his partner had broken up with the VA. The VA would make comments about hurting her/himself because of her/his relationship or would write about hurting other people. The R has never heard anyone call the VA any names including “fat bastard.” The R mentioned that s/he has a partner but did not make the VA feel bad about that but tried to help the VA find a creative outlet through art. The VA’s G noted that the VA did not always report things as they happened and “makes things up.” The G noted that staff persons were good with the VA, and the VA had been doing better since s/he was perscribed different medications. Facility records showed that the VA had numerous incidents where s/he left the facility without supervision with the intent to not return to the facility. Each time staff persons attempted to persuade the VA to not leave or to return to the facility but the VA more often than not would leave. On numerous occasions the facility contacted law enforcement to assist in getting the VA to return to the facility. Facility documentation showed that SP1 and SP2 were trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: On August 29, 2025, the VA was upset about a partner having ended their relationship. SP1 and SP2 attempted to talk the VA about what was troubling the VA but the VA refused to talk and walked away from the facility. SP1 followed the VA and then called SP2 to call law enforcement because the VA was getting close to the highway. The VA stated that during the incident, a staff person called the VA a “fat bastard.” It was also alleged that other unknown staff persons have yelled at the VA causing the VA to feel overwhelmed and engage in acts of self-harm and that the R teased the VA. The VA stated that the staff person that called her/him a “fat bastard,” was the same staff person that was grilling food the day of the incident, so it was determined the VA was referring to SP1. The VA could not recall if anyone else was present to hear SP1 say that. SP1 denied the allegations. The VA also stated that unnamed staff persons yelled at and made comments to the VA but did not provide details regarding incidents. Although the VA stated a staff person, determined to be SP1, called the VA “fat bastard,” and yelled at the VA the day of the incident and it was alleged SP2 agreed with SP1, and the VA stated that staff persons yelled at and made comments toward the VA effecting the VA’s mental health, given that the SP1 denied the allegations and there was no other information to confirm or dispute the VA’s or the SP’s account, that SP2 did not provide information and the VA stated s/he did not recall if anyone else was present during the incident, that P1 and the G stated the VA had a history of providing inaccurate information, and that the VA did not provide details regarding staff persons yelling at him/her and making comments, there was not a preponderance of the evidence whether SP1, SP2, or other staff persons engaged in repeated conduct that would be considered to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be 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, or threatening). Action Taken by Facility: The facility’s Internal Review and Evaluation stated that policies and procedures were adequate and followed, and that no additional training was required. Action Taken by Department of Human Services, Office of Inspector General: No further action taken at this time.
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