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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: 1071472-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) had a lapse in dental appointments between April 2, 2025, and June 30, 2026, including for a filling. As a result, the VA needed a cavity filled and two teeth extracted. Date of Incident(s): Between April 2, 2025, and June 30, 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 July 9, 2026; from documentation at the facility and medical records; and through eight interviews conducted with five facility supervisory staff persons (P1-P5), a facility nurse (N), the VA’s dentist (D), and a representative (R) from the VA’s dental clinic. This investigator also met the VA but due to his/her limited communication skills, the VA was not interviewed for this investigation. Additionally, this investigator called the VA’s guardian (G) and after the G identified him/herself on the voicemail, this investigator left a message about the incident. The G called this investigator back and left a detailed message stating that s/he was not aware of the VA missing any appointments and that the VA’s dental appointments were discussed at the VA’s annual meeting in approximately June 2026, with no concerns noted. This investigator attempted to reach the G again via phone and email to further discuss the report but the G did not respond to this investigators attempts. The VA was diagnosed with intellectual disabilities, maternal rubella syndrome, gastroesophageal reflux disease (GERD), and depressive disorder. The VA was vision and hearing impaired and communicated via tactile sign language, gestures, and physical touch. The VA enjoyed going out to eat, riding his/her bike, and swimming. The Team Meeting Minutes dated June 10, 2026, said that the VA relied on staff persons to schedule, attend, and provide transportation to all medical appointments. The VA relied on staff persons to follow any doctor’s orders received at his/her appointments. P1, P3, and the Incident Report dated June 30, 2026, provided the following information:
· P1 said that s/he began working at the facility in December 2025. At that time, there was no documentation to show upcoming medical appointments so in January 2026, P1 began going through medical referrals to figure out what appointments were needed and then P1 began scheduling appointments because the facility was a “little behind.” This included that the VA had not been to the dentist since April 2025 which “did not seem right.” In approximately February 2026, the N and P2 told P1 that the VA’s dental clinic no longer accepted the VA’s insurance so P1 sent the N emails asking how to go about finding a new dentist for the VA but P1 “never got an answer from anyone.” · In approximately April 2026, P1 was at the main office when s/he asked the N “again” what to do and P2, who was nearby, told P1 to take the VA to the dentist and that the VA could pay for the appointment out of pocket. P1 then called the VA’s dental clinic and learned that the clinic accepted the VA’s insurance and then P1 scheduled the “soonest” available appointment, which was on June 30, 2026. · On June 30, 2026, during the appointment, the D asked P1 why the facility “never followed through” on getting two of the VA’s teeth filled. The D told P1 that at the VA’s last dental appointment in April 2025, the VA needed two cavities filled and a follow up appointment was scheduled in July 2025, but was missed. (Note: There was no information from the VA’s dental clinic or the facility that this was scheduled.) P1 did not know why it was missed because s/he was not employed at that time. The D told P1 that because of the length of time between the April 2025 appointment and the appointment on June 30, 2026, that the VA would need a cavity filled and two teeth extracted. P1 was “shocked” and said that it was “not okay” because the VA could not “care” for him/herself and staff persons were supposed to ensure the VA’s appointments were scheduled. P1 did not think it was “fair” that the VA was the “only one” who should “face consequences for other people’s lack of action.” · P1 then notified P3 of the missed appointment and P3 reached out to the dental office to get records. (Note: P3 was not working at the facility in July 2025, during the time of the missed appointment.) P3 saw that on April 2, 2025, the dental office notified an unknown staff person that fillings were recommended and the unknown staff person said they would notify the G but that s/he “might not do anything.” P3 thought that the dental office was referring to the G not doing anything but said that was just his/her “assumption.” However, P3 said that the G did not need to approve fillings. There was also a dental note on that date that said that the G did not want the VA on a medication due to potential kidney damage but it did not say which medication. · According to P1, the VA had “extremely bad” GERD but the G did not want the VA to use the medication prescribed by the VA’s doctor so the VA used a “holistic powder” that was “very sugary and very acidic.” The VA’s dentist thought the powder “did more harm than good.” The VA had a history of having his/her teeth pulled and the VA’s GERD caused a “lot of erosion” which “led to decay.” · P1 said that scheduling appointments for clients was not assigned to “one person” and that P1’s, P3’s, P4’s, P5’s, and the nurses role, including the N, were to all “assist.” P3 said that at the time of the incident, in April and July 2025, P4 and P5 would have been responsible for ensuring that the VA attended his/her dental appointments. Additionally, the N did an “audit” of the “books” so P1 did not know why the N did not see the missed appointment. P3 also worked another licensed program within REM and another nurse there kept an “eye” on appointments but P3 did know “what [the N] did.” · P1 saw in the VA’s prior dental work paperwork that the VA was seen at the dentist every three months but at the VA’s appointment on June 30, 2026, the dentist told P1 that the VA was to be seen every six months. The VA’s dental office sent reminders for appointments via text message and the number the dental office had previously was for P5. · The VA did not express any teeth pain prior to June 30, 2026. The VA “loved” oral care and going to the dentist. The VA could clean his/her own teeth at home but staff persons did a “once over” at the end. The N, P2, and P4 provided the following information: · The N, P2, and P4 each said that P1’s and P5’s role took the clients to appointments and were supposed to schedule the next appointment before they left the current appointment. Additionally, P2, P3, P4, and the nurses, including the N, did audits which included medical appointments and they “rotated” the audits between the clients which the N said was every three months. However, P2 did not know if any audits were done on the VA’s file during the time of the missed appointment. The N said that s/he did not recall if the audit included reviewing the appointments and said that the audits for the nurses role was new within the past year. However, the N was not aware of the VA missing any appointments. P4 also said that if missed appointments were found during the audits, the house supervisors would be notified. Additionally, the regional director also sent out a list “companywide” of missed appointments. · P2 said that the VA’s appointment was missed “under the eye” of P4 and P5 who were working at the time of the incident. However, the N, P2, and P4 each said that P5 was “amazing” and “really good” at ensuring that appointments were “scheduled and attended” and they did not know why the VA’s appointment was missed. P4 said that if P5 had difficulty getting clients to appointments, P5 would notify a nurse or P4 who would bring them. P4 was not aware of the VA missing any appointments. · P4 said that prior to P5 ending employment, P5 wrote down future appointments because there was a “gap” between P5 leaving his/her role and P1 starting and P5 gave the dates to P4 who gave them to the N. P4 said that the N then put the appointments on his/her calendar and “called” clinics to see if any appointments were missing. The N said that s/he did not recall these things. · The N “believed” that the VA was seen at the dentist annually due to insurance. · If the VA was experiencing pain, s/he would make a “grunting sound.” However, the VA had a “high pain tolerance. The N, P2, and P4 were not aware of the VA expressing pain in his/her teeth. · The VA had GERD but the G “declined” for the VA to be on medications for it, which the VA’s physician was aware of. Because of this, P2 thought that impacted the VA’s teeth and caused “erosion.” The N said that between March and November 2025, the G “finally” put the VA on a medication for GERD which “seems to have helped” but the “damage was probably done” regarding concerns with the VA’s teeth. P5 provided the following information: · P5’s role included scheduling and attending medical appointments with the clients. If P5 could not attend an appointment, the N would take the client. Any missed appointments would be documented in a progress note and staff persons would notify the provider. While P5 was employed, P2 and P4 were both P5’s supervisors. · The VA was initially seen at the dentist every three months due to GERD because the “acid” from GERD was “deteriorating” the VA’s teeth. At some point the VA began seeing the dentist every six months, but P5 did not recall when that was. The VA used to be on medication for GERD but the G stopped it because it could be “bad” for the VA’s kidneys. The VA’s team and doctor were aware that the VA stopped taking it per the G. The G preferred “natural remedies.” Because of that, the GERD was not “controlled.” · P5 did not recall the VA not being seen as scheduled and the VA’s dental clinic would call the facility for reminders of the VA’s appointments and left a message if no one answered. Additionally, the VA had semi-annual in person meetings and one of the documents that was “presented to the team” was the VA’s appointments. It an appointment was missed, it would be “caught” at the meetings. · P5 was not aware of the VA expressing any pain in his/her teeth. The VA had a history of teeth extractions. · P5 stopped working at the facility in November 2025 and thought that the VA’s last appointment prior to that was in the summer or October or September 2025. P5 did not recall any issues at that time. P5 would schedule the VA’s next appointment prior to leaving an appointment and then would document the upcoming appointment in progress notes. P5 also had a “planner” that s/he used to help keep track of appointments where other staff persons could also see the appointments. · When P5 left, there had not been anyone to fill his/her position so prior to leaving, P4 asked P5 to write down upcoming appointments, which P5 did and gave to P4, but P5 did not know what happened to the list. P5 also emailed the upcoming appointments to the N and P4 so that there was a “paper trail.” The nurses also did a monthly audit which included checking appointments. Because the N had a reduced work schedule, another nurse, whose name P5 did not recall, “helped.” The D, the R, and paperwork from the VA’s dental office provided the following information: · The Dental Exam Referral dated March 23, 2023, said that the VA was seen every three months and had “severe erosion.” The dentist was “watching some changes due to acid reflux.” It was “recommended” that the VA take a “higher dose” of medication for acid reflux but the G “did not want [the VA] to take it” so the VA was using “apple cider vinegar.” The VA was to be seen again on June 21, 2023. · On June 21, 2023, it noted that an unknown staff person called one hour prior to the appointment to cancel due to “staff shortage.” The VA was seen again on September 27, 2023, and there was “moderate gum line plaque” and “generalized acid erosion.” · On January 29, 2024, the VA was seen at the dentist and it noted that the VA had “severe erosion” but that “home care looks good.” The VA was to be seen every three months and had future appointments scheduled. · On November 13, 2024, the VA was seen and it noted that the VA’s teeth were “severely eroded” and noted “acid reflux” but no further information. The VA received silver diamine on two teeth. The VA was to be seen again in three months. (Note: There was no information in the dental records that the VA was to have any follow up work done.) · On April 2, 2025, the VA had a cleaning and fluoride treatment. The VA did not have an exam on that date. It further noted that the D felt that the VA would be “gingivally and periodontally stable” at 9 or 12 months because the VA’s insurance “did not cover.” The concern was not “hygiene” but had “more to do with erosion/decay” and that if the VA only had 12-month appointments, exams likely would be “stable” with 12-month cleanings. The dental clinic told an unknown staff person that there were three areas of previously diagnosed decay and treatment of fillings was recommended previously. (Note: There was no documentation in the VA’s dental paperwork to show when this was but the D said it was in November 2024.) The unknown staff person said that s/he would let the G know “again” but that the G “might not do anything.” The VA was to be seen again in six months. · On September 18, 2025, the dental office called and told an unknown staff person at the facility that the VA had “work that needed to be done” due to “decay” and the unknown staff person said that “they know work to be done, but probably will not schedule” but did not provide a reason why. (Note: There was no information regarding who “they” was or the specific work to be done.) · On June 30, 2026, the VA was seen for an exam and cleaning. The VA had “advanced decay” and erosion on two teeth and received a referral for an extraction. The VA had “decay” on another tooth and needed a filling, which was completed on July 7, 2026. The VA was to be seen again in six months. At the appointment for the filling, it noted that it was recommended that the VA have a “soft diet” if possible because the VA’s remaining teeth were “thin” and “weak” and could fracture. · The R said that there were no missed appointments in July 2025. However, the R said that the VA only had two missed appointments total, one in 2022 because the facility van was not working and another in 2023 due to a “staff shortage.” The D did not know if an appointment was scheduled in July 2025 but thought that s/he had recommended that the VA get in more “often” for fluoride to “preserve” the VA’s teeth. The D said that the VA had acid reflux and “erosion” that had been “going on quite a while” and because of this, even if the VA had not missed any appointments, the VA’s teeth “probably” would have needed to be extracted including because they were “slowly eroding” due to the GERD. At some point, the VA was on a medication for GERD but the G took the VA off it because s/he was “worried” about issues caused by the medications. The VA’s Health Needs Record dated February 2, 2026, and completed by the N said that staff persons were to coordinate all recommended and necessary dental appointments. The VA was seen semi-annually and the VA’s last dental appointment was April 2, 2025, where the VA’s teeth were cleaned and polished. Three of the VA’s teeth had cavities and required fillings due to “decay.” However, the VA’s teeth were in “better shape this visit due to better brushing and flossing.” Staff persons were to continue with twice daily brushing and flossing “as tolerated.” Additionally, it said that “will follow up and schedule teeth filling for a later date” but did not note if this was staff persons or the dental offices responsibility. The next exam was on July 29, 2025. (Note: The N did not know where s/he found this date and did not realize that it was a “past appointment” when writing it on the Health Needs Record. However, the N said that at that time, s/he asked P1 to schedule a dental exam for the VA.) P1’s and P5’s position description said that when “applicable,” they were to schedule or assist in scheduling appointments and may accompany clients to the appointments. They were to also oversee the follow-through of orders and communicate with the clients team as appropriate. P3’s and P4’s position description said that they were to “periodically audit” the client files for “accuracy and completion.” They were to also oversee the implementation of individual health care planning and oversee and review health care documentation. This included overseeing coordination of health care appointments and monitoring the clients “attendance.” The N’s position description included completing health assessments and following through on clients medical and dental appointments The Health Service Coordination and Care policy said that the facility was to meet the health service needs of each persons as defined in their plans. P1-P5 were trained on the VA’s plans. The N and P1-P5 were trained on their position descriptions, the Health Needs Coordination and Care policy, and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: According to P1, when s/he first began working at the facility in December 2025, there was no documentation of upcoming appointments so P1 looked at medical referrals and saw that the VA had not been to the dentist since April 2025 (eight months prior). P1 notified the N and P2 who said that the VA’s dentist did not take the VA’s insurance so P1 attempted to figure out what to do and once s/he did so, scheduled the “soonest” available appointment which was June 30, 2026. Although P1 said that on June 30, 2026, the D told him/her that the VA had missed an appointment for fillings in July 2025, there was no documentation from the facility or the VA’s dentist about this. The VA’s dental paperwork on April 2, 2025, said that the VA was to be seen in six months and that also, the VA would be “stable” with an appointment every 12 months. However, the paperwork from the VA’s dental clinic on that date also said that they told an unknown staff person that there were three areas of previously diagnosed decay and treatment of fillings was recommended previously. (Note: There was no documentation in the VA’s dental paperwork to show when this was but the D said it was in November 2024.) Although there were concerns that the VA had not been seen in over a year, had missed an appointment in July 2025, and that an appointment for the VA’s fillings was not scheduled, given that the VA did not express pain; that an appointment was scheduled as soon as it was identified that there was a lapse; that information from all sources was unclear how often the VA was to be seen; that the VA’s dental paperwork dated April 2, 2025, stated the VA would be “stable” with an appointment every 12 months; and that the D said that even if the VA was seen, that s/he probably would have needed to have his/her teeth extracted including due to the GERD, 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility completed a “full audit” of dental appointments to “ensure compliance” for “yearly appointments” and ensure that follow-up and other recommended appointments were scheduled and attended as needed. Additional oversight, direction, and internal procedure was to be created to ensure that appointments and follow ups were not missed by operation and nursing staff. Future employes were to also be trained on these things. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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