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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: 1098078-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was often left in his/her bedroom by a staff person (SP). The VA’s adult disposable brief was not changed as needed and the VA developed sores in his/her peri area. It was also reported that the SP called the VA names. Date of Incident(s): Ongoing, prior to March 23, 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); 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: 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. 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 7, 2026; from documentation at the facility; and through thirteen interviews conducted with six facility staff persons (P1 – P6), a supervisory staff person (P7), a health services coordinator (HSC), two residents (R1 and R2), the VA’s case manager (CM), and the VA’s guardians (G1 and G2). Attempts were made by telephone and letter to interview a staff person (P8), who initially agreed to an interview, but did not respond to subsequent attempts to contact him/her. Attempts were made by telephone and letter to interview a staff person (P9), but P9 did not respond to requests for an interview. The SP was unable to complete a scheduled interview and did not respond to a subsequent telephone request for an interview. The VA enjoyed swimming, bowling, going to amusement parks, going shopping, listening to music, watching YouTube, and visiting with his/her family members. The VA’s diagnoses included Emanuel syndrome (chromosomal disorder), intellectual disabilities, and neuromuscular scoliosis. The VA primarily used sign language and vocalizations to communicate. The VA’s Individual Abuse Prevention Plan stated that the VA was at risk of physical and verbal abuse. The staff persons were to facilitate healthy boundaries between the VA and others. The VA needed support for all of his/her activities of daily living and would not perform those activities without guidance. The VA typically used a walker or a wheelchair for mobility. The VA’s Self-Management Assessment stated that the VA required the assistance of staff persons with dressing, toileting, bathing, skin care, and monitoring skin integrity. The VA’s Nursing Care Plan stated that the staff persons were to assist the VA with changing his/her soiled clothing, washing his/her hands, face, and peri area, combing his/her hair, and brushing his/her teeth. The VA wore adult disposable briefs. The staff persons were to assist the VA to the bathroom every two hours and assist him/her with toileting. The staff persons were to monitor any changes in bowel or bladder elimination. R1 stated that s/he liked the staff persons at the facility and they did not say mean or hurtful things to R1 or the other residents. When another resident was “being loud,” the SP told him/her to “tone it down.” R2 stated that the staff persons treated him/her “good” and s/he never heard the staff persons “get loud.” R2 never heard the staff persons say unkind or insulting things to the residents. The staff persons did not swear and were not mean to the residents. R2 enjoyed living at the facility. G1 and G2 provided the following information: · The VA moved into the facility in December 2025. The VA was supposed to have a 1:1 staff person for eight hours each day, but did not always have that 1:1 staff person available to spend time with him/her and take him/her on community outings. G1 and G2 often took the VA on outings or to their home. G1 stated that initially the VA was very happy to return to the facility after those outings, but that once the SP began working at the facility the VA seemed reluctant to go back to the facility. · P1 told G1 and G2 that the SP “talked horribly” about the residents while the residents were in the room. The SP also sent texts to P1 that said that P1 “hated” all of the residents and “wished their families would just come get them.” The SP called the VA “a little devil bitch.” G1 believed that while the VA might not understand everything the SP said, s/he probably understood that the SP did not like him/her. The VA’s demeanor was different around the SP than around the other staff persons. · G1 stated that when they visited the VA at the facility, the VA’s bedroom typically smelled of urine. On several occasions, urine-soaked adult disposable briefs were left on the bedroom floor. At times, the VA’s bed was wet. At other times there was “smashed up marshmallows” in the VA’s bed and cups of curdled milk sitting on the bed. G1 believed the other residents were able to help keep their bedrooms clean, but the VA was unable to clean his/her bedroom. The VA did not like to take showers and the staff persons told G1 that they could not make the VA shower, so the VA did not regularly shower. G1 and G2 often had the VA bathe when they took the VA to their home. · The VA was unable to change his/her adult disposable briefs and needed the staff persons to take care of the VA’s personal cares. At times, when G1 and G2 went to the facility, the VA’s adult disposable briefs were “full” and “the little beads were coming out.” The VA also began to develop “diaper rash sores” from not having his/her briefs changed regularly and from not bathing regularly. The rashes cleared up when the VA stayed with G1 and G2 and took baths. P1 – P7 and the HSC provided the following information: · The VA required assistance with personal cares, including toileting, dressing, and bathing. The staff persons were to check the VA’s adult disposable brief every two hours. The VA used basic sign language to communicate his/her needs. · P1 stated that the SP told P1 that G1 and G2 “probably didn’t want” the VA in their home because they “don’t want to deal with” the VA. The SP also told P1 that that “nobody wants to put up with” the VA’s behaviors and s/he wished G1 and G2 would “not bring [the VA] back to the facility.” The VA was sometimes present when the SP made those comments and P1 believed that the VA knew that the SP did not like him/her. On one occasion, the SP referred to the VA as a “little devil bitch,” but the VA did not hear the comment. P2 stated that s/he never heard any of the staff persons refer to the VA as the “little devil bitch,” but on several occasions, the SP referred to the VA as “a spoiled brat” while the VA was in the same or an adjacent room. P7 stated that P1 told him/her that when the SP called the VA a spoiled brat, it was “mostly outside” and the VA was not present. On one occasion, P1 told P7 that the SP referred to the VA as a “bitch,” but the SP made the comment outside, away from the VA. None of the other staff persons told P7 that the SP spoke disrespectfully about the VA. The SP told P7 that s/he did not call the VA names. The SP had expressed concerns to P7 as to whether the facility was a “good fit” for the VA because of the amount of personal cares the VA required. · P3 never heard the SP speak disrespectfully about the VA. P4 stated that the SP did not interact with the VA. P4 believed that P2 spoke to the VA in a “firm” tone of voice, but s/he never heard anyone say unkind things to the residents. P5 did not hear the SP speak to the VA in a derogatory manner. P2 stated that when the SP worked at the facility, s/he “literally ignored” the VA and asked the other staff persons to assist the VA. P3 stated that the SP “kind of left [the VA] alone” instead of interacting with him/her. P6 did not see any interactions between the SP and the VA. The HSC was rarely at the facility, but never saw the SP become angry with the VA or other residents or make unprofessional remarks about the residents. P7 stated that the SP began working at the facility in January 2026, but had multiple trainings at a different location, so did not spend much time at the facility prior to the end of February 2026. P7 did not believe that the SP spent much time at the facility while the VA was there and the SP did not have a lot of interaction with the VA because, as a supervisory staff person, s/he was more involved in overseeing the other staff persons than providing direct care to the residents. · P1 stated that at times s/he found dirty adult disposable briefs on the floor of the VA’s bedroom. There were dirty clothes “all over” the bedroom, snack cups full of old snacks,” and milk cups under the VA’s bed. P3 stated that the VA’s cups of milk were sometimes left in his/her bedroom. P4 stated that the VA’s room did not smell of urine. P5 stated that there was an air freshener in the VA’s bedroom and P5 did not smell urine or find dirty briefs on the floor. P6 stated there were sometimes food containers or cups left in the VA’s bedroom, but s/he did not recall the VA’s bedroom smelling bad. The HSC did not recall that the VA’s bedroom ever smelled bad and the HSC did not see food or cups in the VA’s bedroom. P7 stated that s/he did not see old food or cups or dirty adult disposable briefs on the VA’s bedroom floor. P7 had talked to the staff persons about emptying the garbage cans every shift. · P2 stated that occasionally the morning staff persons did not change the VA’s bedding when it was wet. P3 stated that s/he checked the VA’s adult disposable brief every two to three hours, but on some occasions when s/he arrived at the facility for his/her work shift, the VA’s bedding was wet. P4, P5, and P6 each stated that they checked on the VA’s adult disposable brief every two to three hours. There was one occasion when P4 arrived at the facility and found that the VA’s adult disposable brief was “soaked.” P4 stated that the VA never had a rash from wearing wet briefs. P5 stated that the VA was able to sign when s/he wanted to use the bathroom or when his/her adult disposable brief was wet. The VA’s adult disposable brief had always been recently changed when P5 began his/her work shifts. On one occasion, the SP expressed concern to the HSC that the VA was developing redness in his/her peri area and the VA’s physician prescribed zinc oxide. · P7 stated that P1 had interpersonal conflicts with the SP and P6. P7 believed P1 “fabricated” a lot so that P7 had to “weed through” what P1 talked about. P7 stated that P1 told P7 that s/he “didn’t care for” the SP. The CM stated that on December 11, 2025, the VA moved into the facility. G2 told the CM that the SP called the VA “a devil child” and “wished somebody would just run them over with a fucking truck because they were tired of dealing with these people.” G2 also told the CM that the VA’s adult disposable brief and clothing were “completely soaked” when s/he woke in the mornings. Facility documentation showed that the SP, P1 – P7, and the HSC each received training on the Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies, and the VA’s plans prior to the incidents. Conclusion: Regarding the VA being left in his/her bedroom without his/her adult disposable brief being changed, causing sores in the VA’s peri area: G1 and G2 stated that at times when they went to the facility, the VA’s adult disposable briefs were “full” and the VA also began to develop “diaper rash sores” from not having his/her briefs changed regularly. The staff persons provided consistent information that they checked the VA’s adult disposable briefs every two to three hours. The HSC stated that on one occasion, the SP expressed concern that the VA was developing redness in his/her peri area and the VA’s physician prescribed zinc oxide. Other than one occasion of redness in the VA’s peri area, none of the other staff persons had concerns about the VA developing a rash or bedsores. Although the VA’s adult disposable brief was sometimes “soaking” when it was checked, given that it was possible for that to occur within the two to three hours between checks and that when redness was observed staff persons had the concern addressed, there was not a preponderance of the evidence whether there was a failure to provide care or services to the VA which were reasonable and necessary to maintain the VA’s physical health and 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). Regarding the SP using derogatory language about the VA: P1 stated that on one occasion, the SP referred to the VA as a “little devil bitch,” but the VA did not hear the comment. The SP also made comments about G1 and G2 not wanting the VA in their home. P2 stated that the SP sometimes called the VA a “spoiled brat” while the VA was in the same or an adjacent room. None of the other staff persons told P7 that the SP spoke disrespectfully about the VA and the SP told P7 that s/he did not call the VA names. P7 stated that the SP had limited interactions with the VA and there were interpersonal conflicts between P1 and the SP. Although P1 and P2 each stated that the SP called the VA a spoiled brat when the VA might have been within hearing distance, given that no information was provided that the VA heard the comments or reacted to them, that none of the other staff persons had concerns about the SP’s interactions with the VA, and that the SP denied making the comments to P7, there was not a preponderance of the evidence whether the SP’s comments 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 completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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