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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: 1109894-AFC (Adult Foster Care) Investigator(s): Christine Cavanaugh 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person’s (SP) child (C) pinched a vulnerable adult (VA) and the VA sustained bruises. The SP said s/he would “remain neutral” and refused to get involved or resolve the situation. Date of Incident(s): Unknown prior to July 7, 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 16, 2026; from documentation at the facility and county adult protection; and through six interviews conducted with the VA’s case manager (CM), the VA’s guardians (G1 and G2) who were also the VA’s family members, an administrative/supervisory staff person (SP), the C, and the VA. The VA lived in the facility home with the SP, the SP’s spouse and two children including the C who was 12 years old, and another client who was also the VA’s family member. The home was two stories with a walkout lower level. The VA’s bedroom was on the lower level, and the SP and his/her family members’ bedrooms were on the upper level. The main floor had an open floor plan which included a dining room, kitchen, living room, den, and bathroom. The lower level included two bedrooms, a full bathroom, family room, and storage room. The Program Abuse Prevention Plan stated that it was difficult to supervise clients who went outside on their own, especially from the basement exit and difficult to supervise activities in the lower-level bedroom area; however, frequent check-ins were completed during waking hours. Clients’ bedrooms were “private spaces” and limited the staff persons ability to supervise in those areas. To reduce potential abuse/harm, the clients did not go outside unsupervised, and staff persons were to follow the clients’ plans for supervision needs. The VA enjoyed watching TV, reading, and playing with animals. The VA’s diagnoses included mild intellectual disability, autism, disassociation disorder, anxiety, depression, oppositional defiant disorder, reactive attachment disorder, post-traumatic stress disorder, expressive/receptive language disorder-severe, attention deficit hyperactivity disorder, hypersomnia, and anorexia. The VA’s file said that the VA was “very imaginative” and told stories that s/he was a character in a movie/book that s/he encountered and needed to be “oriented of the reality” and current situation. The VA had “balance problems” and needed reminders to sit including times when s/he was standing while putting on socks which caused him/her to lose his/her balance. The VA had a 24-hour supervision plan of care. The VA’s Individual Abuse Prevention Plan (IAPP) stated that staff persons should remain with the VA “all the time.” The VA engaged in self-injurious behaviors; however, the IAPP did not provide additional information on that. The VA told a law enforcement officer (LEO) and this investigator that s/he was happy living at the facility and spent his/her time reading or watching TV. The VA bruised easily and on an unknown date, while watching Netflix, the C pinched the VA’s arm. The VA pointed to his/her right upper arm where the pinch happened, but at that time (July 16, 2026) there was no visible bruise. The VA said that it happened more than once but did not provide additional information or details. G1 provided the following information: · On an unknown date in June 2025, the VA told G1 that sometime between April and May 2025, the C pinched him/her but did not provide additional information or details. · Around July 2-4, 2026, while on vacation with the VA, the VA showed G1 and others who were there, several “fairly fresh” bruises that included at least two on each arm and were close in proximity. The bruises were “blueish and greenish”; one bruise was about a “quarter size,” and the smallest one was “dime-sized.” G1 did not take any photos of the bruises at that time but took photos of two remaining bruises about a week or so later. (Note: Copies of the photos were requested but not received by the completion of this investigation.) The VA told G1 that the bruises were from the C pinching him/her. G1 did not think that bruises on the upper arms could have been from something other than what the VA said they were from. · G1 then told the SP what the VA said and the SP told G1 s/he was “going to stay neutral.” G1 said s/he probably “misinterpreted” what the SP said a “little bit;” however, it “seemed” like the SP did not want to talk about it. · The VA had a history of “telling stories” and trying to “get people into trouble;” but also had a history of reporting things that did happen. In this case, there was “physical evidence” to support what the VA said. · G1 had no other concerns with the SP or the facility and said that “they are wonderful people” and “do a good job” supervising the VA. G2 heard about the incident from G1 and did not have any prior concerns. The VA was a “little bit of a storyteller;” however, G2 felt like the information regarding the incident was accurate. The CM stated that s/he heard about the incident on July 7, 2026, from G1 who provided information to the CM that was consistent with the information G1 provided during his/her interview. After talking to G1, the CM talked to the SP. The SP said that his/her use of “stay neutral” was more of a “clinical term” meaning not “prioritizing” one side over the other. The SP also told the CM that the C denied pinching the VA and that the C and VA did not have any unsupervised time together. The CM said the VA had a history of providing inaccurate information but could not provide any examples. The CM had no prior concerns with the SP or the facility. County adult protection investigated the allegation for immediate protection needs of the VA. Their report provided the following information: · On July 9, 2026, a county worker (W) visited the home. The VA told the W that s/he was recently camping with G1 and other family members. The VA said that no one in the home ever pinched him/her but pulled up the right arm of his/her long sleeve shirt and pointed to a bruise that was just below his/her right shoulder. The bruise was round and about an inch and a half in diameter. It was “black” and “blue” but “slightly faded” and “not bright in color.” The VA said s/he also had a bruise on his/her right hip and “might” have some others on his/her lower legs. The VA said the bruises were because s/he falls “a lot” because s/he was not very stable on his/her legs and therefore sustained bruises on his/her arms, knees, shins, and sometimes lower back. The VA denied that the C pinched him/her. · The SP told the W that G1 told him/her about the allegations and that s/he “can’t say for sure it didn’t happen as [s/he] isn’t with [the VA] and [the C] 24 hours a day.” The SP said s/he did not see any physical contact between the VA and the C. The SP spoke to the C and told the C not to have any physical contact with the VA. The SP also said that s/he thought the VA “has it out” for the C and it was not the first time the VA made allegations against the C. A few weeks prior, there was an incident where the VA intentionally scared the C with a porcelain doll and the C screamed “very loudly.” The SP did not want to appear that s/he was “taking sides” but denied stating s/he did not want to “get involved” with the incident. · The SP also said the VA recently spent five days with G1 and the bruises on the VA’s upper arm appeared newer so it “didn’t make sense” to the SP that the bruises could have come from the C. The C said that s/he liked having the VA live with him/her and that the VA “brings positivity.” The C denied pinching the VA and/or ever being home with the VA without staff persons. On an unknown date, the C went downstairs to get the C’s ball and saw the VA sleeping on the couch. The C “gently tapped” the VA’s upper arm and asked if s/he wanted to sleep in his/her bedroom instead. The VA then went to his/her bedroom. The C also said that on an unknown date, the VA tried to scare the C with a doll. Now, the C does not “go close” to the VA.
The SP provided the following information: · On July 5, 2026, G1 told the SP that the VA had a bruise on his/her right arm and said that it was from the C pinching the VA and that about a year prior, the VA said that the same thing occurred. The SP was not aware of any concerns prior to that. The SP told G1 that s/he did not think the C pinched the VA and that s/he would be “on a neutral side.” The SP also told the G that s/he would talk to the C and that s/he would have the C avoid interacting with the VA. When the SP talked to the C, the C denied pinching the VA. The SP stated that his/her comment about being “neutral” did not mean that s/he was not going to get involved, but that s/he was “in the middle.” · The VA had a history of being “unstable” and falling including against the walls and/or bumping him/herself. Because the VA bruises easily, these incidents might cause bruises on the VA. Prior to July 5, 2026, the SP did not see any bruises on the VA and when s/he saw a bruise on that date, it looked “fresh” and purple and was about one inch long and half an inch wide. The VA also had bruises on his/her legs that s/he said were from mosquito bites. · The SP said it was “hard to say” when/if the VA was telling the truth about something and G1 told the SP that the VA had a history of “making stories.” The SP was not aware of the VA having any self-injurious behaviors that would cause bruising. · The SP, G1, and CM had a meeting to discuss the concerns and a “safety plan” was put in place. Since it was “unavoidable” to have encounters between the VA and the C since they lived in the same home, the agreement was that the C would not have any unsupervised time with the VA or go to the basement without staff supervision. · The SP was aware of a time when the VA scared the C with the VA’s doll. The SP was trained on the Reporting of Maltreatment of Vulnerable Adult’s Act and the VA’s plans. Conclusion: Information obtained showed that on an unknown date in June 2025 and around July 2-4, 2026, the VA told G1 that the C pinched him/her. Between July2-4, 2026, the VA showed G1 bruises that s/he stated were from the C pinching the VA. The VA told this investigator and the LEO that the C pinched him/her more than once but did not provide additional details or information but told the W that the C did not pinch him/her. The SP was not aware of any concerns about the C pinching the VA until July 5, 2026, when G1 told him/her about it. The C denied to the SP and this investigator that s/he pinched the VA and stated that on an unknown date s/he “gently tapped” the VA’s upper arm to wake the VA. Information was consistent that the VA was not always an accurate reporter of information, but G1 and G2 believed that the incident was true because the VA had bruises. Although the VA had bruises, given that the VA had a history of providing inaccurate information and provided conflicting information regarding whether the C pinched him/her, that the C denied pinching the VA, and that there was no information to support that the SP or any other staff persons did not supervise the VA in accordance with the VA’s plans, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with care or supervision which was reasonable and necessary to obtain or maintain the VA's physical or mental health or safety. There was not a preponderance of the evidence 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 their policies and procedures were adequate and followed and that there was no identified lapse in supervision or staff performance. As a “preventative measure” the facility will continue the existing requirement that the C has no unsupervised contact with the VA or other clients and that the C will remain under the supervision of staff persons when interacting with clients and will not independently enter resident areas, including the basement. Action Taken by Department of Human Services, Office of Inspector General: On September 3, 2026, the facility was issued a Correction Order for not allowing the VA to watch television by him/herself.
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