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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: 1069985-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden beth.virden@state.mn.us 651-431-6572 Suspected Maltreatment Reported: It was reported that more than once, a staff person (SP) made nontherapeutic statements to a vulnerable adult (VA), including calling him/her “fucking disgusting” and/or “fucking annoying.” Date of Incident(s): August 15 and 16, 2026; and ongoing
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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 14, 2026; from documentation at the facility; and through eight interviews conducted with the VA’s guardian (G) who was also the VA’s family member, the VA’s case manager (CM), the VA’s housemate (H1), facility staff persons (the SP, P1, P2, and P3), and a supervisory staff person (P4). This investigator met the VA and another housemate (H2) at the facility; however, they were not interviewed due to their limited communication skills. Another housemate (H3) was not present at the time of the site visit but was described as having similar limited communication skills and was also not interviewed. The VA’s support plans, including Individual Abuse Prevention Plan, provided the following information: · The VA enjoyed coloring, doing arts and crafts, watching TV, and participating in community activities. · The facility provided at least one staff person 24 hours a day, who helped guide, redirect, and support the VA as needed. The VA sometimes struggled to complete tasks, like bathing, grooming, and using the toilet. Staff were to encourage the VA to complete his/her own tasks to the greatest extent possible and to assist the VA as needed. · The VA communicated using “non-specific behavioral changes,” facial expressions, and gestures, which were familiar to those who knew him/her. “[The VA’s] cues require staff interpretation and monitoring.” The VA might indicate “discomfort” through vocalizations, screaming, and other behavioral responses. The VA benefited from a “calm and predictable” environment with “supportive staff” who knew him/her. · Due to the VA’s “significant cognitive and communication challenges,” s/he might not identify dangerous situations and/or keep him/herself safe if s/he encountered a “hostile person.” Staff were to intervene as needed, guide the VA to safety, and report concerns on the VA’s behalf. · The VA’s diagnoses included autism spectrum disorder and severe intellectual disability. The VA and H1-H3 lived together at the facility, which was a one-level house. All the housemates’ bedrooms were down a set of hallways from an open-concept kitchen, dining and living room. P1-P4 and facility documentation provided the following information: · P1-P4 provided consistent information that the VA was “nonverbal” and communicated using gestures and “grunting.” The VA might shake his/her head, “No,” if s/he did not like someone. The VA might push something away if s/he did not want it, like food. If the VA was excited, s/he might clap and if the VA was “upset,” s/he might grunt. · P1 said that s/he heard the SP make “rude comments” to the VA “constantly” or about four to five times over the past nine months (approximately November to August 2026). One time, P1 heard the SP tell the VA something like, “No wonder you don’t have any friends.” At least once, P1 told the SP, “Don’t bully the clients.” One time, P1 told P4 about the SP’s conduct and P4 held an all-staff meeting to address “bullying.” [Note: The facility’s Meeting Agenda and Training showed that during an all-staff meeting on November 21, 2025, the facility provided training on professional boundaries, harassment, and bullying. The training stated that “bullying,” included verbal abuse, such as derogatory remarks and insults; and verbal or physical conduct that a reasonable person would find threatening, intimidating, or humiliating. Staff were to treat everyone with respect. The SP, P1, P3, and P4 attended the meeting.] · P4 and the facility’s personnel records provided consistent information that on May 26, 2026, P4 met with the SP to address concerns about the SP’s statements to the VA. During that meeting, the SP confirmed that s/he told the VA, “This is why [wo/men] don’t like you. You are disgusting. [Wo/men] are supposed to be the disgusting ones.” The SP explained to P4 that s/he was “joking” and that his/her statement was not directed at the VA. P4 told the SP that it did not matter if s/he was joking because s/he did not know how the VA interpreted the SP’s statements. The SP agreed to watch his/her statements and tone of voice in the future. · P3 said that one time prior to July 30, 2026, s/he saw the VA touch his/her own groin to indicate that s/he needed to use the bathroom; the VA typically used this gesture to indicate a bathroom need. However, the SP said, “right to” the VA, something like, “You’re disgusting. No [wo/man] is going to want you.” P3 did not see if or how the VA responded. P3 told P4 about the incident. P3 said that this incident was not the sole time P3 heard the SP say such things to the VA. “[The SP] did say gross things other times,” but P3 could not recall the details. [Note: It was unclear if P3’s account was the same account provided by P4 and personnel records dated May 26, 2026. However, forthcoming in this report, the SP provided information about different circumstances, than P3’s account, in which s/he said something to the VA about wo/men not finding the VA attractive.] · P2 said that on August 15 and 16, 2026, s/he worked with the SP and P1. At one point, P2 heard the SP say, “directly to” the VA, “[The VA’s first name] needs to stop pissing [his/her] pants because it’s fucking disgusting.” The SP said that s/he (the SP) was going to vomit because “[the VA’s] piss reeks.” The SP said, “[The VA’s first name] is 40 something years old and [s/he] needs to stop pissing [his/her] pants like a baby.” P2 described the SP’s tone of voice, when s/he said these things, as like someone might use if they were “scolding a dog.” P2 was confident the VA heard the SP’s statements. The VA immediately looked like s/he was about to cry, which “threw [P2] off” because the VA “never” cried. P2 saw the VA’s eyes “well up with” tears and the VA’s “smile went down to, like, a straight grin.” P2 told the SP that the VA was an adult and needed to be treated like an adult and that the SP should not make such statements. The SP told P2, while still in front of the VA, “It’s just getting ridiculous. It’s disgusting and I’m sick and tired of it.” At that point, P2 momentarily stepped outside the facility because s/he was “literally so upset” by what the SP was saying in front of the VA. P2 said, “Thankfully,” there were no other clients around at the time. When P2 returned inside, s/he remained next to the VA on the couch. “I let [the VA] know that, you know, by sitting by [him/her] that I’m here for you and ain’t nobody gonna get between us.” At one point, the VA put his/her head on P2’s shoulder. · P2 added that “throughout” his/her shifts on August 15 and 16, 2026, between 10 a.m. and 7 p.m. each day, s/he saw the SP, at least once, “mocking” the VA when the VA made “grunting noises” asking for help; this was done in front of the VA. One time, P2 heard the SP say, in front of the VA, “[The VA] is fucking annoying and needs to grow the hell up and start acting like the adult [s/he] is.” At least once, P2 verbally intervened and more than once, P2 called and emailed P4. · P1 said that s/he worked with the SP and P2 on August 16, 2026. At one point, the VA pointed to his/her own groin and then pinched his/her own nose, which historically meant that the VA had either been incontinent or needed to use the toilet. However, the SP said to the VA, “That’s fucking disgusting,” “You’re gross,” and “You should not piss your pants all the time.” The VA was sitting next to P1 on the couch at the time and the SP’s statements were directed at the VA. P1 was confident the VA heard the SP’s statements. The VA immediately made a face, which P1 interpreted as, “[The VA] knowing [s/he] did something wrong but not knowing what [s/he] did wrong.” The VA had a “help me” look in his/her eyes. P1 immediately told the SP that his/her statements were “not appropriate.” P1 then told the VA, “It’s okay to have accidents. Everyone does, including me,” and the VA laughed at this. P1 said that the SP engaged in similar conduct towards the VA “throughout” P1’s shift, 10 a.m. to 7 p.m. P1 called and emailed his/her concerns to P4. · P4 said that on August 17, 2026, s/he returned to work after time off and discovered numerous calls and emails from P1 and P2 regarding the SP’s conduct on August 15 and 16, 2026. P1 and P2 then each approached P4 to tell him/her about their concerns. P1 and P2 each said that the SP made statements to the VA, including that the VA was “fucking disgusting” and “fucking annoying,” and at least once, the SP told the VA that his/her urine “reeked.” P1 and P2 each said that this occurred throughout their shifts on August 15 and/or 16. P4 then asked to speak to the SP about the allegations, but the SP voluntarily ended his/her employment, and the conversation did not occur. P4 asked the VA about the SP, and the VA responded by putting his/her head down and shaking his/her head, “No.” P4 interpreted the VA’s response to mean that s/he was “not fond of” the SP. · P1 said that in the past s/he saw the VA “make noises” towards the SP, which P1 interpreted as meaning the VA did not like the SP. · P2 said that the VA was “typically more distant” towards the SP. If the VA wanted help with something, s/he grabbed P1’s or P2’s hand but did not grab the SP’s hand, which P2 interpreted as meaning the VA did not want the SP to help him/her. P2 said that the VA was not doing this earlier in 2026 and it seemed to be more of a “recent” behavior (e.g., not wanting the SP to help him/her). · P1 said that if s/he was a client and the SP said these same things to him/her, P1 would feel “humiliated, downgraded, like a low life.” P2 said that s/he would feel “like crap.” P3 said that s/he would feel “embarrassed, singled out, and like my staff doesn’t care about me.” P4 said that s/he “would not handle it gracefully.” · P4 added that although the VA’s expressive communication skills were limited, at times the VA appeared to understand what was said to him/her, but the VA’s responses “did not always go with” the conversation. [Note: At the time of the site visit, when this investigator met the VA, the VA made vocalizations and gestures but did not respond with words or in a recognizable manner. However, when this investigator commented on the VA’s colorful shirt, the VA held out his/her shirt and looked down at it. The VA did not communicate a recognizable response but seemed to understand the reference to his/her shirt.] The CM said that the VA might not always understand what was said, but s/he seemed to “catch things going on around [him/her].” “[The VA’s] receptive communication is stronger than [his/her] expressive communication.” The VA would understand if someone was “being mean.” The CM said that if s/he was a client and a staff person called him/her “fucking disgusting, fucking annoying,” the CM would feel “pretty dang horrible.” The G said that the VA would understand a person’s tone of voice and when someone was “not happy.” “[The VA] would know that you were mad at [him/her].” The G said that if s/he were a client and a staff person called him/her “fucking disgusting, fucking annoying,” the G would describe the staff person as being “pretty nasty.” The SP provided the following information: · Regarding the incident in May 2026, including that the SP called the VA “disgusting” and said that the VA would not get a wo/man, the SP recalled that the VA was “farting” that day, and the SP told the VA, “You’re never going to nail a [wo/man] like that. Unless you find a [wo/man] that wants to eat farts.” The SP said that s/he was “joking,” and that s/he would “never” say such a thing to a client and “mean it.” · Regarding the other allegations, including on August 15 and 16, 2026, the SP “never” said any of the alleged statements to the VA. The SP said, “That hurts my heart that someone would say I said that.” The SP did not know why the allegations were made but said that other staff were “bullying” him/her. The SP routinely held other staff accountable and “complained a lot” when staff were not doing their jobs. The SP did not report his/her concerns to a supervisor because the supervisor was part of the problem. · The VA did not communicate with words but might “whine” or “sulk” if s/he was “upset.” The VA might “rudely grunt” if s/he did not like someone. If the VA wanted help from a certain staff person, s/he focused on that staff person. The VA did not typically get “sad-sad.” · The SP and the VA got along well when other staff, like P2, were not working. P2 “babied” the VA, which made the VA less likely to do things that s/he could do him/herself. However, regardless of who was working, the VA’s needs were always met. If the VA asked the SP for help, the SP helped him/her. H1 said that s/he typically stayed in his/her bedroom; however frequently heard noises from other areas of the facility. H1 never heard a staff person swear at a housemate or call a housemate nontherapeutic “names.” Sometimes staff were “stern” when talking to a housemate. The facility’s Service Recipient Rights Policy stated that all clients had the right to be treated with courtesy and respect. Facility documentation stated that the staff persons interviewed for this investigation received training on the VA’s support plans, including Individual Abuse Prevention Plan, the facility’s Service Recipient Rights Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), states, in relevant part, that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion: A. Maltreatment: P1-P3 provided consistent information that more than once between November 2025 and August 2026, they saw the SP “mocking” the VA and calling the VA “fucking disgusting” or “fucking annoying.” Although the SP denied the allegations, the SP told P4 and this investigator that s/he made similar nontherapeutic statements about the VA’s “farts” in May 2026 and P4 pointed out that if the SP was joking when s/he said these things, they did not know how the VA interpreted the SP’s statements. P1, P2, and P4 provided consistent information that they each saw the VA react towards the SP, including shaking his/her head, “No,” or being “more distant,” which they interpreted as meaning the VA was “not fond of” and did not like the SP; and this would reasonably indicate that there was something about the VA’s relationship with the SP that was not favorable to the VA. Therefore, despite the SP’s information that s/he was bullied by staff persons, there was no information to support that and without additional information to discredit P1-P4 or explain why P1-P4 would all have similar accounts, it was determined that P1’s-P4’s accounts were more credible than the SP’s account. The SP’s conduct included, more than once, calling the VA nontherapeutic names and swearing at the VA or “mocking” the VA’s disabilities, which was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human services and facility’s policies and procedures and were a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6). Although the VA was unable to verbally describe how the SP’s conduct impacted him/her, P1-P3 each said that the SP’s statements were said in front of the VA and P1 and P2 each saw the VA immediately react to the SP’s statements by almost crying and/or having a “help me” look in his/her eyes. In addition, P1-P4, the G, and the CM each provided information that had a staff person made similar statements to them, they would feel “pretty dang horrible,” “like crap,” and “like my staff doesn’t care about me.” Therefore, there was a preponderance of the evidence that the SP’s conduct towards the VA was not an accident or therapeutic and produced, or could reasonably be expected to produce, emotional distress and included the use of repeated or malicious oral language or treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the VA’s care and supervision. The SP received training on the VA’s support plans, including Individual Abuse Prevention Plan, the facility’s Service Recipient Rights Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. In addition, the SP was told more than once that his/her conduct was not appropriate, including through a staff meeting in November 2025, a corrective conversation with P4 in May 2026, and through various conversations with other staff; yet the SP’s conduct continued. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, abuse resulting in serious injury, or financial exploitation of a vulnerable adult if the value of the funds or property is $1,000 or greater. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated emotional abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The SP was responsible for a single incident of maltreatment because each single interaction would not rise to the level of emotional abuse, so it was considered a pattern of behavior, which did not meet the definition of being serious maltreatment. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP was no longer employed. The facility provided additional training to all other staff regarding professionalism in the workplace and the Reporting of Maltreatment of Vulnerable Adults Act. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. Given that the facility took immediate corrective action, a correction order was not issued for the violation outlined above.
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