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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: 1067773-H_CRS (Home and Community-Based Services-Community Residential Setting) 1067769-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported that a staff person (SP) raised his/her voice toward a vulnerable adult (VA) due to the VA being incontinent and that the SP exposed the VA’s genitals to other staff and other residents in a common area while personal cares were completed. Date of Incident(s): Unknown Date 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 February 27, 2026; from documentation at the facility; and through five interviews conducted with the VA, two facility supervisors (P1-P2), the VA’s guardian (G), and the SP. Documentation showed the VA enjoyed music, especially Bobby Vinton and Engelbert Humperdink. VA1 also liked going to libraries that had coffee shops. VA1’s diagnoses included mild intellectual disability, spinal meningitis, and paraplegia. VA1 used a wheelchair for all mobility, and a stand lift was used to assist the VA with personal cares. The VA’s plans showed the following information: · The VA’s Support Plan Addendum showed that staff persons provided the VA with “verbal encouragement” to use the bathroom every two hours to maintain his/her skin integrity. Regardless of prompts, the VA was often incontinent multiple times per day. (Information showed that around 2023, the VA developed open sores on his/her coccyx that required wound care services and a catheter. The catheter was eventually removed in December 2024.) · The VA was prescribed a medication to treat overactive bladder, sudden urges to urinate, leaking bladder, and to help his/her bladder relax and hold more urine. · The VA’s Individual Abuse Prevention Plan stated that s/he “may make false claims or inaccurately report details.” The facility was a one-level side-by-side townhouse with two bedrooms on each side. The facility was converted into one four-bedroom facility. The north and south sides of the facility were a mirror reflection with the two bedrooms on each outside wall. The north side had a living room/common area and two bathrooms. Prior to the investigation the VA’s used the bathroom closer to his/her bedroom, however started to use the larger bathroom which was down the hallway on the north side of the facility. The smaller bathroom had a small entry area (2-3 feet in length) with a closet, just outside of the bathroom and that area connected to the hallway. The VA provided information during and after a previous investigation that the SP told the VA s/he was “wet” in the presence of other residents which resulted in the VA feeling “embarrassed.” The VA initially denied that anyone swore at him/her, however later the VA said, “It happened.” However, the VA did not “remember who did it.” The VA said while completing personal cares the SP would bring the VA out of the bathroom and put an absorbent undergarment on the VA in the common area. The VA said that happened “every day,” and the VA felt embarrassed because other residents saw this occur. The VA provided the following information to this investigator: · The VA said the SP had not raised his/her voice or used any derogatory statements toward the VA. · The VA said the SP assisted the VA with personal cares on an unknown date while in the bathroom. The VA said the SP moved the VA just outside the bathroom and his/her pants were “half-way down,” but the VA had an absorbent undergarment on at the time. The VA said s/he was in the common area for only a “few seconds,” but other residents saw the VA before the SP brought the VA back into the bathroom. Later in the interview the VA said s/he was not wearing undergarments during the incident and was embarrassed by the situation. · The VA was unable to answer if s/he was moved to the common area during a single event or if s/he was moved outside the bathroom multiple times. · The VA said s/he recently started using a different larger bathroom, and everything was fine since s/he started to use the larger bathroom. P1 did not have any firsthand knowledge regarding the allegation, but said the bathroom the VA used previously was small which caused difficulty for staff to complete the VA’s personal cares. P1 had not been informed by any other staff person or resident that the VA was assisted with personal cares in the common area. P1 said the VA had a history of exaggerating things and did not always provide accurate information. P2 said s/he did not have any firsthand knowledge regarding the allegation, but the VA said s/he was uncomfortable with the SP changing his/her absorbent undergarment in a common area. P2 said after a conversation with the VA the facility had implemented a tracking system to address the VA’s incontinence discreetly.
The G said s/he did not have previous concerns with the facility or any specific staff person. The G added that the VA had a history of not providing accurate information. The SP denied changing the VA’s absorbent undergarment in the common area. The SP said s/he would complete the VA’s personal cares in the bathroom, and the VA’s genitals were not exposed to any other person in the facility. The SP said s/he had adjusted the VA’s pants in an area directly outside the bathroom because they were not completely around his/her waist. The SP denied raising his/her voice at the VA. The SP said the VA was not an accurate provider of information. Facility documentation showed that staff persons received training specific for the VA, and training on the Reporting of Maltreatment of Vulnerable Adults Act, individual rights, and positive behavior supports prior to the allegations. Conclusion: On an unknown date or dates, the SP was providing personal care assistance to the VA, and the SP allegedly moved the VA into a common area before completing the VA’s personals cares exposing the VA’s genitals. The VA initially stated that s/he was wearing an absorbent undergarment while being just outside the bathroom, and his/her pants were "half-way down," but later stated s/he was not wearing an absorbent undergarment, which led to feelings of embarrassment after being seen by other residents. The SP denied changing the VA's undergarment in the common area and stated all personal cares occurred in the bathroom. The SP stated that s/he only "adjusted" the VA's pants just outside the bathroom because they were sagging. P1 and P2 did not have any firsthand knowledge of the incident, and no other resident or staff persons informed P1 or P2 of any information that this occurred. Multiple persons, and facility documentation expressed concerns regarding the VA’s ability to provide accurate information. The VA's statements regarding whether s/he was wearing undergarments at the time of the incident were inconsistent, and there was no information which corroborated that the VA’s genitals were exposed during the alleged incident. Given that, there was not a preponderance of evidence whether the SP failed to provide the VA with reasonable and necessary cares and services. 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 the policies and procedures were adequate, but were not followed. The facility did not believe there was staff persons misconduct. The facility ensured the VA’s safety and privacy by having him/her use a larger bathroom, and retrained staff persons on client dignity, person-centered support, confidentiality, professionalism, and factual documentation practices. There were no similar past incidents, and the SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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