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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: 1081006-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA) a “fat piece of shit,” a “pervert,” and a “retard,” which will be referred to throughout the remainder of this report as “r word.” The SP also made negative comments about the VA’s hygiene. Date of Incident(s): April 28, 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 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 May 20, 2026; from documentation at the facility; and through six interviews conducted with two facility staff persons (P2 and P4), two supervisory facility staff persons (P1 and P3), the VA’s guardian (G), and the VA. Attempts were made to contact the SP via phone and United States Mail, but the SP did not respond to requests to be interviewed. The VA was diagnosed with depression, schizophrenia, and an anxiety disorder. The VA enjoyed playing video games, listening to music, working at his/her job, going on walks, and utilizing public transportation to access local stores. The VA’s plans stated that s/he was vulnerable to abuse due to his/her “trusting nature” and was unlikely to “retreat from abuse” as a result. The VA lived at the facility with three other clients. The facility had a main floor and a lower level. The VA’s bedroom was in the lower level along with a shared common space, an office, a bathroom, and a laundry room. Beyond the laundry room was another door that led to an unfinished storage space. The storage space was sometimes referred to by staff persons as the “cement room” as it was lined with cinderblocks. The VA provided the following information: · On an unknown date in April 2026, the VA ordered Dairy Queen through a delivery service using his/her funds for two of his/her housemates and him/herself. At around 1:15 or 1:30 p.m., the food was delivered and the VA walked back inside the facility to the kitchen with several bags of food. The SP said to the VA, “Congratulations,” as the SP began to slowly clap his/her hands. The SP then said, “Don’t expect me to be cooking for you anymore.” The VA thought that the SP did not believe the VA that the food was going to be shared with VA’s housemates. · The VA and the SP began to argue and “yell” at each other, and the SP called the VA a “pervert,” a “r word,” and a “fat piece of shit.” The SP told the VA that s/he did not “bathe” much. The SP at some point said, “Get out here big [guy/girl],” and the SP said that s/he would “kick [the VA’s] ass.” The VA did not go outside, saying that s/he was not going to fight the SP. · The VA was really upset, angry, and was hurt by some of the things that the SP said. The VA started to “tear up” as the SP put on his/her shoes, walked out the door, and walked out of the facility. The entire incident took about five minutes or less and the VA could not remember everything that was said because s/he was so angry. The VA took an as-needed medication (PRN) because the incident was giving him/her an “anxiety attack.” · The SP had not called the VA names before or “clapped at” the VA on prior occasions. · P1 was inside the facility at the time of the incident and heard some of the incident. P3 was between two shifts, asleep on the living room couch when the incident began. · The VA stated, via the Internal Review, that s/he was “scared” that s/he may be “poisoned” by another staff person who had personal ties to the SP outside of the facility. Information from the Internal Review, P1, and P3 provided the following information regarding April 28, 2026: · P1 was working and P3 was sleeping on the living room couch between shifts during the incident. · According to P1, the time was approximately 1:15- 1:30 p.m. and s/he was on the main floor when s/he saw and heard the SP began to clap his/her hands, but P1 did not pay much attention to it at the time as the SP tended to “pace” and clap his/her hands at times. P1 went downstairs to the cement room to look for a folder. Some days, staff persons and the clients at the facility “got loud” while playing video games with one another, so P1 heard some yelling, but initially did not think much of it. P1 then heard the SP say, “You’re a fat piece of shit,” so P1 went upstairs immediately. The VA was crying and the SP said something to the VA about showering. P1 got between the SP and the VA, comforted the VA, and told him/her to go enjoy his/her food. The SP then grabbed his/her shoes and left. P1 stated that the SP said, “I fuckin’ quit.” · According to P3, P3 awoke when the SP was yelling at the VA for purchasing food. P3 was slow to wake, but heard the VA tell the SP that the food was for some of the housemates, but the SP was not really listening to the VA. The SP was “verbally assaulting” the VA, yelling at a volume of a “seven” out of a scale of one being a whisper and ten being screaming at the top of his/her lungs. P3 heard the SP say some “insults” to the VA regarding the VA’s weight, and the SP called the VA “a fat ass.” The SP also asked the VA if s/he wanted to “go to the door,” which P3 thought the SP either wanted to fight the VA, or that the SP was about to leave the facility. The SP also called the VA something the “r word,” but P3 could not recall what word the SP used in front of the “r word.” P3 stated s/he heard the SP use the “r word” one time. P3 could not recall if the SP called the VA a pervert or told the VA s/he was lying. The SP also made comments about the VA’s hygiene or being “dirty.” · P1 said s/he notified P2 immediately and spoke with the VA, who provided information consistent to what the VA provided to this investigator, and added that the SP called the VA, “a fucking liar.” P1 did not know that the SP’s clapping was in a negative way toward the VA until after the incident. · P1 stated that after the incident, at about 2 p.m., the VA was crying, was “anxious,” and was mad. The VA punched a pillar inside the facility, but did not injure his/her hand, so P1 gave the VA a PRN for anxiety, which helped. · P1 stated that s/he had not heard the SP use inappropriate language toward any clients prior to this incident, but one time was written up for using inappropriate language in front of a client’s case manager, while inside the facility. P2 was contacted by P1 right after the incident. P2 then notified the G and others on the VA’s team. G2 and P2 provided information consistent with what the VA and P1 stated. P2 and P4, who were not at the facility when the incident occurred, had not previously witnessed similar behavior from the SP. P1, P2, and the G stated that the VA was reliable when providing information. P4 stated that the VA was generally accurate, but sometimes stories got “jumbled” when the VA was retelling things. All staff persons interviewed for this report and the SP were trained on the VA’s plans and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information was consistent that on April 28, 2026, at around 1:15 or 1:30 p.m., the VA walked outside to get a food delivery. When the VA brought several bags of food inside the facility to share with his/her housemates, the SP began clapping, and said, “Congratulations,” and made comments to the VA about the food, not believing that some was for the VA’s housemates. The VA provided consistent information that the SP called the VA the “r word,” a “fat piece of shit,” a “pervert,” and made comments related to the VA’s hygiene. P1 and P3 were at the facility and heard yelling between the VA and the SP so P1 went to the kitchen where the VA and the SP were and got in between the SP and the VA. The SP then left. P1 heard the SP tell the VA, “You’re a fat piece of shit.” P3 stated that s/he did not hear all what was said but hear the SP call the VA the “r word.” The SP’s behavior was inconsistent with the standards of a professional caregiver working in a facility licensed by the Department of Human services. Given that there was consistent information that the SP called the VA names including the “r word,” yelled at the VA, and made comments about the VA’s hygiene, there was a preponderance of the evidence that the SP’s conduct was malicious oral language toward the VA that was reasonably considered to be disparaging, derogatory, and humiliating, and would be reasonably expected to cause the VA emotional distress. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident or serious because it did not meet the statutory definition. Action Taken by Facility: The facility’s Internal Review stated that the VA’s plans were adequate but not followed. There was no need for additional staff training and the SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: During the course of the investigation, it was discovered that a staff person working at the facility did not have a completed background study. On June 18, 2026, the facility was issued a $200 fine for the background study violation. The Order to Forfeit a Fine is subject to appeal.
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