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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: 1102152-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 supervisory staff person (SP) did not allow three vulnerable adults (VA1, VA2, and VA3) to sit in the living room and watch television or to drink the beverages of their choice. The SP made VA2 exercise each day and did not allow VA2 to go outside or engage in activities. The SP yelled at VA1 and VA2. Date of Incident(s): Ongoing, prior to April 10, 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 28, 2026; from documentation at the facility and law enforcement records; and through thirteen interviews conducted with five facility staff persons (P1 – P5), a supervisory staff person (P6), the SP, VA3, VA1’s guardian (G1), VA2’s guardian (G2), VA3’s guardian (G3), VA1’s and VA2’s case manager (CM1), and VA3’s case manager (CM2). Due to their diagnoses, VA1 and VA2 did not provide information about the incidents. VA1 enjoyed using his/her iPad, watching television, watching YouTube videos, going out to eat, going for drives, and spending time with his/her family members. VA1’s diagnoses included moderate intellectual disabilities, autism spectrum disorder, and neuronal migration disorder with heterotopias and pachygyria. VA1 communicated with sign language, gestures, and vocalizations. VA1’s Risk Assessment Plan stated that VA1 engaged in self-injurious behaviors, such as hitting him/herself in the face and head with his/her hands and fists. At those times the staff persons could implement sensory integration techniques to help calm VA1. VA1 had no understanding of how to report abuse and would not be able to tell others to stop the abuse. VA1’s Risk Assessment Detail stated that when VA1 displayed self-injurious behaviors such as disruptive vocal behaviors, repetitive behaviors, physical aggression, or self-harm, the staff persons were to use redirection techniques as soon as they saw any of the above behaviors. The redirection techniques included asking VA1 what s/he wanted, assessing VA1 for any medical conditions such as a headache, checking for any disruptions to VA1’s schedule, and then offering VA1 a break from his/her activity and setting a timer to show VA1 how long the break would last. After a break, the staff persons “must always” resume the task until completed. If redirection did not help VA1 calm, the staff persons could offer VA1 an “as needed” medication. VA1’s Action Plan stated that it was important to VA1 to know what to expect each day and to have consistency in his/her daily schedule so that s/he did not display interfering behaviors. VA1’s Action Plan Summary stated that the staff persons were to document when VA1 displayed physical aggression, self-injurious behaviors, and agitative behaviors, as well as whether VA1 was compliant with daily requests and expectations and participated in emotions check-ins. Each day VA1 was expected to participate in some form of physical activity. At least twice a month, VA1 was encouraged to participate in social activities such as going for a drive, going out to eat, or other quiet activities. Noisy activities or activities that included groups of people could trigger VA1’s self-injurious behaviors. VA2 enjoyed looking at magazines, doing puzzles, watching television, going out to eat, listening to music, being outside, and going for walks. VA2’s diagnoses included moderate intellectual disability, autism spectrum disorder, depression, obsessive-compulsive disorder, and seizure disorder. VA2 was unable to communicate verbally, but used vocalizations, gestures, and behaviors to express him/herself. VA2’s Occupational Therapy Consultation Report stated that VA2 had reduced access to his/her community due to difficulty in redirecting VA2 away from grabbing drinks and magazines. In the past, VA2 attempted to drink cleaning chemicals. VA2 had a history of becoming fixated on food or drinks and compulsively looking through the cabinets and refrigerator for specific food or drink items. A visual timer was used to help VA2 understand the timing of events. VA2’s Positive Supports Report stated that VA2 was fairly “rigid” on the things s/he liked. VA2 had a “highly concentrated” interest in paper, especially magazines. When in the community, VA2 often became fixated on taking papers or beverages and “would stop at nothing to obtain them,” including breaking into cars, taking items from people, and pushing people to get what s/he wanted, which caused safety concerns. VA2’s Risk Assessment Plan stated that VA2 was unable to identify potentially dangerous situations and could not tell others to stop the abuse. VA2 would not know how to report abuse. When in the community, VA2 might run towards items s/he wanted, such as magazines, food, or beverages, without regard to those around him/her. In the past, VA2 took items, including beverages and papers, from neighboring homes and vehicles. VA3 enjoyed going out to eat, going shopping, watching movies, coloring, playing Bingo, and spending time with his/her family members. VA3’s diagnoses included severe intellectual disabilities, seizure disorder, hemiplegia, cerebral palsy, and oropharyngeal dysphagia. VA3 attended a day program each weekday. VA3’s Risk Assessment Detail stated that VA3 was at risk of abuse and would be unable to protect him/herself from abuse or report abuse. Due to VA3’s diagnoses, s/he might not understand or know if s/he was being verbally abused. VA3 provided inconsistent gestured answers about whether there were staff persons or activities s/he liked or disliked at the facility. P1 provided the following information: · Each day, all of the VAs were on schedules that the staff persons were expected to follow. When VA1 and VA2 showered, they were not allowed to hold the shower spray nozzle and the staff persons were not allowed to help them dry themselves because they “needed to be more independent.” The VAs were only allowed to have milk once or twice a week when they had cereal. The milk was stored in the garage refrigerator where the VAs did not have access to it. VA2 was only given water to drink and VA1 was only allowed two glasses of juice at mealtime. P1 did not believe any of the VAs had a medical reason for a fluid restriction. When P1 asked to take the VAs on walks or into the backyard, s/he was told that it was “not allowed.” None of the VAs were taken on community outings. VA1 and VA2 spent most of each day in their bedrooms. At 7 p.m., the VAs ate dinner and by 8 p.m. they “had” to be in their bedrooms. · VA1 was able to communicate with his/her iPad, but when P1 asked if s/he could work with VA1 to expand his/her use of the iPad to communicate, s/he was told not to do so. VA1 sometimes hit his/her head with his/her fists while s/he repeatedly said, “No.” VA1 had to do “stair steps” and complete three puzzles each morning before s/he was allowed to use his/her iPad. Twice each day, VA1 had to use the treadmill for 30 minutes. The SP frequently “yelled” at VA1 to put on his/her shoes so that s/he could use the treadmill. At times, if VA1 was using the treadmill and began hitting him/herself and yelling “No,” the SP would scream at VA1, turn the treadmill to a faster speed, and loudly play music that VA1 hated. The SP then reset the timer so that VA1 used the treadmill for 30 more minutes. · VA2 typically spent each day in his/her bedroom, where s/he played with blocks and a box of paper. The staff persons did not socialize with VA2 and VA2 was not allowed to have milk, juice, or coffee. When P1 brought a container of coffee into the facility, s/he was told that s/he could not have it because VA2 would take it. VA2 was not allowed to enter the kitchen and the staff persons blocked VA2 with their bodies from entering the kitchen and “loudly” told VA2 that there was nothing for VA2 in the kitchen. On one occasion, P1 gave a magazine to VA2 and looked at it with him/her. The following day, s/he was told by P3 to not bring any other magazines. · VA3 went to a day program each weekday, so P1 did not usually work with him/her. When VA3 was not at his/her day program, s/he typically watched television or sat in his/her chair. When P1 took crafting items to the facility for VA3 to use, s/he was told that s/he had to take the items away because VA2 would want to take the paper items. P2 – P6 provided the following information: · Consistent information was provided that VA1 had a schedule that s/he followed every day and that s/he became upset if the staff persons “messed up” his/her schedule. The staff persons did not have to tell VA1 what activity was next on the schedule because VA1 “knew what to do.” The staff persons were trained to provide positive reinforcement to VA1 to help keep him/her calm. VA1’s care plan included 30-minutes of physical activity twice a day. When VA1 occasionally refused to use his/her treadmill the staff persons encouraged VA1 to use it. P2 believed that the SP typically got VA1 to use the treadmill, but none of the staff persons heard the SP give VA1 an “ultimatum” about using the treadmill. If VA1 became agitated while using the treadmill, the staff persons, including the SP, had VA1 get off the treadmill. P4 stated that VA1 got along very well with the SP and typically listened to the SP when s/he asked him/her to do something like use the treadmill. VA1 could push the buttons to start and stop his/her treadmill. VA1 frequently chose to listen to the radio and often set the timer for his/her activities. VA1 sometimes went on walks or car rides with the staff persons and went on community outings with his/her family members. P3 stated that the SP did not tell the staff persons that VA1 could not use his/her iPad to communicate with them. · VA2 typically did not want to do anything that was not part of his/her regular routine. If a staff person asked VA2 if s/he wanted to go for a walk or go outside or do an activity, VA2 typically said, “No.” It was difficult to take VA2 into the community because s/he “sprinted” toward cars and tried to get into them and take drinks or papers, but the staff persons took him/her out to eat occasionally and to medical appointments. P6 stated that the staff persons were discouraged from bringing papers to the facility for VA2 because then VA2 expected it every time that staff person arrived at the facility and would “aggressively” look for it. The staff persons offered activities to VA2, but VA2 had the ability to choose what s/he wanted to do and typically did not do anything s/he did not want to do. VA2 told P2 and P4 that s/he did not want to go on walks. · If VA2 saw milk in the refrigerator, s/he usually tried to drink the whole container, so the staff persons kept smaller cartons of milk in the kitchen refrigerator and larger containers in the garage refrigerator. VA2 sometimes fixated on looking for items around the facility and “constantly” looked through the kitchen cupboards. At those times, the staff persons attempted to redirect him/her, but did not prevent VA2 from looking through the cupboards because s/he would push past them. P2 never heard a staff person tell VA2 that s/he had to go to his/her bedroom and did not think VA2 would go to his/her bedroom unless s/he wanted to do so. P2 stated that the SP typically acted “very gently” with the residents, but sometimes used a more “no nonsense” tone when talking to them. If beverages were left sitting out, VA2 would drink them all. · VA3 spent weekdays at his/her work program and frequently went on community outings with his/her family members. VA3 enjoyed watching television and napping. · P3 and P5 had no concerns with how the SP interacted with the residents and believed that the SP knew how to work with the residents because s/he had worked at the facility for years. P3 never heard the SP yell at VA1 while VA1 showered. The only time the SP spoke loudly to VA1 was when VA1 began to make “really loud vocals” and the SP had to speak loudly in order to be heard by VA1. P6 stated that the SP was “kind of [VA2’s] person.” None of the staff person told the VAs they had to be in their bedrooms by 8:30 p.m. P6 stated that s/he wrote the VAs’ schedules with the assistance of positive behavior support professionals because it helped the VAs be successful and not have behaviors. The VAs’ guardians went over the VAs’ support plans during interdisciplinary team (IDT) meetings. · P3 and P6 each stated that there were interpersonal conflicts between the SP and P1 because the SP wanted the staff persons to do things in a particular manner. The SP provided the following information: · The SP typically worked at the facility from 6 a.m. to 2 p.m. In the past, at mealtime VA2 took juice and other drinks from VA1 and VA3. The staff persons began to use “juice enhancers” for all the VAs so that VA2 did not see anyone else getting a different colored drink. The staff persons used to serve coffee to the VAs, but it triggered VA2’s seizers. The staff persons had individual-sized cartons of milk that they served to VA2 in a glass because VA2 would want to drink all the milk in a larger container. If VA2 took milk from the refrigerator, the staff persons allowed him/her to have it. Although the staff persons documented what each VA ate each day, the VAs were not restricted on how much they could eat or drink. When the VAs showered, they liked to hold the shower nozzle themselves. The SP did not tell the staff persons that the VAs could not hold the shower nozzle. The SP usually assisted VA3 with his/her showers and the other staff persons assisted VA1 and VA2. The SP stated that when s/he helped VA1 with showering s/he never yelled at VA1. The SP “tried” to take the VAs on community outings, but was not always able to do so. · VA1 enjoyed watching videos on his/her iPad, but did not always use the iPad to communicate with others. The SP encouraged VA1 to use his/her iPad to communicate. The staff persons did not limit VA1’s use of the iPad. VA1 had a daily schedule that s/he followed. VA1 did not drink milk, and was typically given a cup of water, two cups of juice, and then more juice if s/he asked for it. VA1 had been doing daily “step-ups” and walking on the treadmill since before the SP began working at the facility and those things were part of his/her daily schedule. VA1 usually did his/her exercises without prompting. If VA1 refused to do an activity, the SP never threatened to turn on music that agitated VA1 and VA1 could choose to do something else. The SP did not play music on his/her cellphone that VA1 disliked and did not increase the speed of the treadmill. If VA1 began to hit him/herself while using the treadmill, the SP believed VA1 would be unsteady and might fall. In the evening, VA1 often turned off the television in the living room when s/he was done watching it. None of the VAs were told they had to go to their bedrooms. · VA2 went through “phases” on activities s/he wanted to do, such as puzzles, coloring, or building with Lego blocks, and then s/he would stop doing those activities. VA2 did not go into the community very often because s/he became overstimulated and frequently tried to take drinks and papers from community persons. VA2 liked to go to the lake in a nearby park. Occasionally VA2 would “go back and forth” around the facility and look for items. The staff persons would ask VA2 if they could help him/her find something, but sometimes VA2 could not find what s/he was looking for and became very agitated and the staff persons could not redirect VA2. At those times they might administer VA2’s as needed medication to VA2 to help him/her calm so that s/he did not hit the staff persons. The staff persons did not prevent VA2 from being in the common areas of the facility. The staff persons were allowed to bring papers or magazines into the facility for VA2 to look through.
· VA3 enjoyed going to his/her day program during the week and to church with his/her family members on Sundays. VA3 typically returned from his/her day program at approximately 3:30 p.m. · The SP believed P1 was upset with the SP because the SP told P1 that s/he should not spend a significant amount of time going outside each hour for smoke breaks, which meant that not all of the daily chores were getting done. The SP told P6 about P1 taking long breaks. G1 stated that VA1 was mobile, but needed the assistance of the staff persons with many of his/her personal cares. VA1 used a communication program on his/her iPad and some sign language to communicate with others. VA1 enjoyed using his/her iPad, but the staff persons limited VA1’s use of the iPad so that s/he engaged in other activities besides using the iPad. If VA1 became agitated, s/he sometimes engaged in self-injurious behaviors. VA1 enjoyed looking through magazines and paper items. VA1 did not like change and sometimes became agitated when things changed. G1 believed VA1 “did better” when there was a routine for him/her to follow. VA1 “always” asked for food, but VA1 lost a significant amount of weight in the past and it was important to keep his/her weight under control. The facility was located in a small town, so there were not a lot of activities or stores for VA1 to go to. When G1 visited VA1 at the facility, the residents were “content.” G2 stated that VA2 was “obsessive” about drinks and “loved” to take coffee or water bottles from others. VA2 communicated with vocalizations. G2 believed the SP and P6 were very supportive of VA2 and were “really good” with VA2. They ensured that VA2 was safe when in the community and tried to take him/her to activities, but VA2 had difficulty with wanting to take drinks or papers from others so they sometimes had to shorten the outings. G2 had no concerns about VA2 being told to remain in his/her bedroom and when G2 visited VA2, VA2 was typically sitting in the common areas of the facility. VA2 enjoyed looking at magazines and the staff persons encouraged VA2 to look at one at a time so that when they went to VA2’s physician’s office, VA2 would understand s/he should only take one magazine at a time. G3 stated that VA3 enjoyed going to his/her day program. G3 did not believe that VA3 participated in many activities at the facility other than watching television. G3 was uncertain if there were staffing issues that prevented VA3 from going into the community more often. G3 took VA3 to most of his/her medical appointments because there were no staff persons to take him/her. G3 “totally trusted” the SP to care for VA3 and G3 believed VA3 was happy at the facility. G3 also believed the staff persons treated the residents “fine.” CM1 stated that VA1 had a speech program on his/her iPad that s/he could use, but VA1 did not always want to use it for anything besides games. VA1 typically wanted to play on his/her iPad unless the staff persons tried to interest VA1 in other activities. If VA1 did not want to do something, s/he might engage in self-injurious behaviors. VA1 was very routine oriented and liked to follow his/her schedule and liked to have structure in his/her day. CM1 stated that in the past, the SP maintained structure for VA2 and CM1 believed VA2 had more behaviors when the SP was not present. The staff persons kept a certain amount of milk and juice in the kitchen refrigerator, but kept the majority of the drinks in a garage refrigerator because if VA2 got a gallon of milk from the refrigerator, s/he would drink it all until s/he became sick. VA2 had access to everything, but in limited quantities. In the past, VA2 left the facility without supervision and took drinks and papers from the neighbors’ homes and cars. Those issues were discussed at VA2’s team meetings. The staff persons typically took VA2 to the park or on car rides, where s/he would not be exposed to drinks or paper belonging to others. VA2’s family members wanted VA2 to continue living at the facility because of the support VA2 received there. CM1 had no concerns about the care VA1 and VA2 received at the facility. CM2 stated that VA3 enjoyed going to his/her day program each weekday. VA3 needed assistance with walking and used a wheelchair for longer distances. CM2 did not think that VA3 was taken on outings very often because of staffing concerns. The facility offered to take VA3 to his/her medical appointments, but G3 typically took VA3 to the appointments. CM2 believed VA3 would enjoy going on drives and going to the movies or out to eat more often. P1 provided seven undated video recordings taken on his/her cell phone. The recordings provided audio, but not video content, except for one video that showed the feet of two people walking past P1. During all of the recordings, one of the VAs could be heard making vocalizations, but it was unknown whether it was VA1 or VA2. P1 provided information that the staff person speaking in the recordings was the SP, although it was not possible to verify that it was the SP speaking or to whom s/he was speaking. The seven recordings provided the following information: · The SP repeatedly said “no,” followed by vocalizations from VA1 or VA2. The SP told the VA to “let go of me,” “turn around,” “your room,” and “I have been talking to you a lot today.” · A computer voice asked the SP for “more juice please,” and the SP said, “That’s two, you are done.” · The SP said, “Oh, no, we are not doing that. Do I need to put some music on?” · The SP told one of the VAs to get his/her shoes because they know what they do after snack and no one will do it for them. One of the VAs laughed several times. · The SP said, “I have talked to you three times, every day, we are not doing nothing different today. Go get your sweater.” The SP then said, “Go,” repeatedly, speaking in a sterner tone of voice. · The SP said, “No,” repeatedly and then told the VA to get his/her sweater in his/her room. · The SP said, “You are doing the same thing you are supposed to be doing every day, put it on, go tie your shoe.” The facility’s Service Recipient Rights policy stated that the residents were to be free from restraint, time out, seclusion, or restrictive intervention and were to be treated with courtesy and respect. The residents were to be able to engage in chose activities and access their personal possessions at any time and were to have free access to common areas of the facility. Facility documentation showed that the SP, P1, P2, P3, P4, P5, P6 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: Regarding the SP not allowing VA1, VA2, and VA3 watch television in the living room, to drink the beverages of their choice, to go outside, or to engage in activities: Although it was reported that the VAs were not allowed to go on community outings, consistent information was provided by the staff persons and by the VA1’s and VA2’s plans that VA1’s and VA2’s outings were limited because they might engage in self-injurious behaviors or cause safety concerns while on community outings. VA3 attended a day program each day and frequently went on community outings with family members. Although the staff persons encouraged the VAs to do things such as take walks, the VAs routinely refused to do so. While P1 stated that the VAs were forced to stay in their bedrooms, consistent information was provided by the other staff persons that the VAs typically went to their bedrooms when they wanted to and were not told to do so by any of the staff persons. VA2’s beverage consumption was limited because VA2 would refuse to stop drinking any amount of beverages that s/he accessed. While it was reported that the SP did not allow the VAs to go on community outings, drink the beverages of their choice, or to remain in the main living areas of the home, given that the VAs’ plans included information about limiting community outings and certain beverages, and that consistent information was provided by the SP and other staff persons that the VAs were not restricted from any areas of the home, there was not a preponderance of the evidence whether there was a failure to supply the VAs with care or services which were reasonable and necessary to maintain the VAs’ physical or mental health or 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 yelling at VA1 and VA2 and forcing VA1 to exercise: Although information was provided that the SP yelled at the VAs and forced VA1 to follow a daily schedule and use the treadmill even when s/he did not want to, given that the other staff persons provided consistent information that the SP did not yell at the VAs or force them to exercise and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP used repeated oral language toward the VAs that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening and could reasonably be expected to produce emotional distress to the VAs. 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, but were not followed by the staff persons. After the incident, all the staff persons received additional training on the VAs’ plans and some of the staff persons received additional training on maltreatment reporting and on their job descriptions. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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