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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: 1123340-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that staff persons did not brush a vulnerable adult’s (VA’s) teeth which led to multiple cavities and dental extractions. Date of Incident(s): Ongoing and prior to June 12, 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 August 28, 2026; from documentation at the facility and medical records; and through eight interviews conducted with two facility supervisory staff persons (P1 and P2), three staff persons (P3, P4, and P5), the VA’s guardian (G1), who was also the VA’s family member, the VA’s case manager (CM), and the VA’s dentist (D). Additionally, attempts were made via phone and email to interview a staff person (P6) and another guardian (G2) but the attempts were unsuccessful. This investigator met the VA but due to his/her diagnoses, this investigator did not interview the VA. The VA was diagnosed with autism, generalized anxiety disorder, and expressive speech disorder. The VA enjoyed spending time with his/her family members and being outside. The VA’s support plans said that brushing the VA’s teeth was within the “scope” of services that the VA received at the facility. Staff persons were to use hand over hand prompting to assist the VA with task completion including teeth brushing. The VA was unable to “manage” dental appointments but would “participate with support.” The facility, G1, and G2 were to assist the VA in scheduling dental appointments. According to the VA’s Behavior support Plan, the VA displayed behaviors when s/he was “prompted” to do an “unpreferred” task or when s/he was supported by an “unpreferred” staff person. The VA had a history of hitting, kicking, pushing, scratching, or throwing objects at others. Staff persons were to give the VA time to prepare between transitions; use “first/then” language; use preferred activities to aid in completing undesired tasks; and use counting methods such as “1…2….3 and then” to redirect the VA to an unpreferred task. The VA also had a limited variety of foods that s/he liked including chicken nuggets, chips, and cookies. The VA also preferred juice. The VA was the only client who lived at the facility. Information from the facility showed that there were two staff persons scheduled for every shift. G1 and dental records provided the following information: · On June 12, 2026, the VA had a six-hour surgery to have 12 fillings and 2 teeth pulled because the VA’s teeth were “decayed.” The VA also had two teeth that were “saved” but those were “very weak.” G1 said that this was caused by staff persons not brushing the VA’s teeth despite staff persons stating that they did at least once a day. · G1 also had concerns that staff persons let the VA eat cookies daily and did not brush the VA’s teeth after. The D recommended that the VA not eat cookies but G1 said this would be “hard” due to the VA having “few” foods that s/he ate. However, G1 told the facility that because of this, they should “try” to brush the VA’s teeth three times a day, including after the VA ate cookies. G1 also said that the VA only drank juice that was high in sugars and only ate six or eight foods that were “hard and crunchy,” which “contributed” to the VA’s teeth “decay.” · Staff persons needed to provide “complete physical assistance” when brushing the VA’s teeth but it was “difficult” for staff persons because the VA would hit or be “physical.” Staff persons should not ask the VA if s/he wanted to brush because the VA would say, “No.” Staff persons should “count” while brushing the VA’s teeth and “stack” the VA’s cares which included brushing the VA’s teeth while the VA was in the bath because the VA enjoyed bubble baths. The VA also had two staff persons each shift so staff persons could also ask the other staff person to try. G1 had given the facility a “cheat cheat” and sent the facility “long emails” with the tips “multiple times” but each time a new supervisor came to the facility, they “acted” like they did not know how to work with the VA. The facility told G1 that the VA had the “right to refuse” dental care and that there was “nothing” they could do but G1 said that was not an “excuse for neglect.” · G1 was typically at the facility every other day and brushed the VA’s teeth when s/he was there but the VA was also “really resistant” with him/her which to G1 showed that staff persons were not brushing the VA’s teeth. Brushing the VA’s teeth had “always” been challenging for both G1 and G2. The VA also required sedation at the dentist. · Additionally, since the appointment in June 2026, there were “new” staff persons who told G1 that they “try” to brush the VA’s teeth but the VA “resists.” However, G1 said that they did not know the VA and were “learning.” The newer staff persons were “better” than the former staff persons. · G1 said that flossing the VA’s teeth would be “lovely” but s/he wanted staff persons to focus on brushing the VA’s teeth because flossing would be a “lot.” · At some point, the facility had a hygiene log in the bathroom to document teeth brushing but around April 2026, this was no longer there and G1 was told by the facility that it could not be located. However, the facility added it back in August 2026. The hygiene log that showed that staff persons were “consistently” brushing the VA’s teeth and staff persons told G1 that they were brushing the VA’s teeth but it was “pretty obvious” that they were not doing so because the VA’s teeth were in “bad shape.” G1 said that putting the toothbrush in the VA’s mouth was “not brushing.” · The VA’s teeth became “worse” prior to moving to the facility when the VA lived at another facility and “lost several teeth” there. (Note: The VA moved into the facility in March 2024.) P1 provided the following information: · According to P1, staff persons should brush the VA’s teeth twice daily, in the morning and evening. However, this was “hard” because the VA was “not very good” regarding letting staff persons brush. When staff persons tried to brush the VA’s teeth, the VA would typically push or hit them or throw his/her toothbrush. When that occurred, staff persons were to try again later or try when the VA was in the bath. Staff persons could also ask another staff person at the facility, since there were always two staff persons, and at times three staff persons, if P1 was present. Additionally, G1 typically came to the facility daily and brushed the VA’s teeth when s/he visited. G1 told staff persons that s/he preferred to brush the VA’s teeth while there and did not need help. · Since the VA’s dental surgery in June 2026, most staff persons, including P1, P3, and P4 were new and trying to build a “rapport” with the VA. However, they “cared” and were doing “pretty good” regarding providing cares to the VA. · The facility trained staff persons to ensure they understood the importance of caring for the VA’s teeth. However, the VA also had the “right to refuse” but staff persons needed to be “persistent” unless the VA was “really getting agitated.” · P1 had never seen the VA independently brush his/her teeth. P1 had not flossed or brushed the VA because the VA would not let P1 near his/her mouth. Staff persons should document when they brushed the VA’s teeth. P4 provided the following information: · At some point, G1 told P4 that staff persons who worked prior to P4’s employment did not brush the VA’s teeth so the VA had cavities and needed teeth pulled. G1 told P4 that s/he “wished” that those staff persons took “more initiative” regarding brushing the VA’s teeth and to “just get the toothbrush” in the VA’s mouth, even if the VA “allowed it for one second.” · P4 was told by who s/he thought was a staff person (P7), but did not recall because s/he was “really bad with names,” that the VA did not like staff persons of P4’s gender and that only the opposite gender should “approach” the VA. However, as P4 got to know the VA, P4 saw that the VA was more comfortable with some staff persons than others, no matter the gender. The VA “really liked” a staff person (P8) and let P8 brush for “five seconds.” There was another staff person (P9) who P4 had seen brush the VA’s teeth. P4 did not brush the VA’s teeth because the VA did not “like” P4 and only “tolerated” him/her. P4 tried to brush the VA’s teeth but the VA became “violent” towards him/her including “hitting.” Staff persons were trained to have other staff persons attempt when that occurred which P4 did. The VA “really liked” P3, who P4 often worked with, so the VA “allowed” P3 to brush his/her teeth. · Staff persons documented the VA’s teeth brushing in a binder in the bathroom, which was “pretty new.” Things had gotten a “little better” since June 2026, when the VA had the dental surgery but staff persons could still not “brush for a full two minutes” or brush the VA’s tongue but it depended on the day. P4 did not think that the VA would let staff persons floss. · The VA ate a “lot” of “sweets” including cookies and used to eat them in the mornings but P4 took the “initiative” to not have the VA eat them so early especially due to cavities. P3 provided the following information: · P3 said that s/he was the VA’s “preferred” staff person so P3 assisted the VA with brushing his/her teeth and other hygiene tasks such as bathing. However, it took a “lot of coercing” to brush the VA’s teeth and the date of the site visit was the “first” day that P3 was successful in doing so and said that the VA “stood there for five minutes.” Prior, the VA would say “no” and “smack a wall” if s/he did not want to brush. · Staff persons did “task stacking” which included brushing the VA’s teeth while the VA was taking a bath because the VA “loved bubble baths.” If the VA refused to brush, staff persons would try again. Staff persons would also count. Staff persons documented when they brushed the VA’s teeth in a hygiene binder. · P3 was aware that in June 2026 the VA had surgery for his/her teeth and said that was “heart breaking.” P3 did not work at the facility at that time but said that all the current staff persons were “super proactive” with the VA and P3 had no concerns. P2 provided the following information: · The VA had a history of refusing to brush his/her teeth and would hit staff persons when s/he did not want to brush. If staff persons asked the VA to brush his/her teeth, the VA would say, “No.” However, when staff persons told the VA that they were going to brush his/her teeth, the VA was “more willing” but may still refuse and hit but staff persons “always tried.” The VA only allowed staff persons to brush his/her teeth while in the bathtub but the VA often chose to take multiple baths a day. When staff persons were able to brush the VA’s teeth, it was only in the front because the VA would not let staff persons brush the back and would “swat” their hands away. The VA would typically not allow staff persons to brush longer than 30 seconds before the VA “yanked” staff persons hands away. The VA also would not let staff persons floss. · P2 saw staff persons brushing the VA’s teeth and the VA was “more willing” to let some staff persons brush including P5 and two staff persons (P10 and P11) but often refused with staff persons who were the same gender as the VA including two staff persons (P13 and P14). The VA would also not let G2 brush his/her teeth. There was only one staff person (P12) that P2 had concerns with who was “lazy” in general but P12 stopped working at the facility in approximately 2025. · G1 and G2 “complained” that staff persons “never did enough” but P2 said that staff persons “tried their hardest.” G1 “refused” to train staff persons or let them watch him/her to learn how to brush the VA’s teeth. · G1 and G2 provided a binder that was in the bathroom for staff persons to document the VA’s cares, including when the VA brushed his/her teeth. When the VA refused to brush, staff persons documented that but G1 took photos of the refusals and sent them to the VA’s team asking why the VA refused. G1 further said that there was “no reason” that the VA should be refusing and that staff persons should “offer” to brush the VA’s teeth throughout the day, which staff persons did, but they could not “force” the VA. At some point, a supervisory staff person (P15) removed the binder because staff persons were also documenting the VA’s cares online and P15 did not want staff persons to document in two places but G1 and G2 were “mad” when this was removed. · It took a year to get the VA to see the dentist because the VA needed to be sedated. At some point P2 scheduled a dental appointment but G1 was “mad” that P2 did so and wanted to be the one to schedule the VA’s appointments. It was “very hard” to get the VA to an appointment because G1 and G2 needed to be there and the VA could be “very aggressive.” When the VA went in June 2026, s/he had a “lot of cavities” but P2 said this was in part due to the VA eating a lot of sugar including cookies and juice. The VA ate and drank “junk” and sugar “all day long” which was not “helpful” regarding the VA’s teeth. After the June 2026 appointment, G1 told staff persons that the VA could only eat cookies if s/he brushed his/her teeth after, which staff persons “tried” to do. Staff persons also tried to have the VA eat healthier foods but G1 and G2 said that was the VA’s “preferred foods.” Staff persons also tried to give the VA water but the VA threw the water at them. · The VA had dental concerns prior to moving to the facility and had teeth removed prior to moving in. P5 provided the following information: · Staff persons brushed the VA’s teeth “every time” the VA bathed which at times was five to six times a day. The VA had certain staff persons s/he “allowed” to brush his/her teeth, including P5, and other staff persons who s/he did not. The VA had a history of refusing, including with G1, and would say, “No” and grab staff persons hand. If staff persons did not stop, the VA would “hit” them or throw things. Staff persons were to “communicate” that they were going to brush his/her teeth. Staff persons were to be “persistent” with the VA and provide “routine.” P5 did not have any concerns that staff persons were not attempting to brush the VA’s teeth. · At some point, staff persons had a log in the bathroom to document the VA’s cares including teeth brushing but an unknown supervisory staff person took it away and said it was “not necessary and not required.” However, staff persons still documented this online. · The VA “loved” to eat “sweets” including cookies and chips and “only drank” juice. Staff persons tried to redirect the VA and P5 told the VA that once s/he brushed his/her teeth, then s/he could eat the cookies. In June 2026, the VA went to the dentist and had cavities and it was recommended that the VA no longer eat the cookies but if the VA didn’t, s/he would get “mad.” · At some point prior to June 2026, P2 tried to take the VA to the dentist but the VA hit P2 in the eye and then hit the dentist so then G1 began taking the VA. The Internal Review and Hygiene Log provided the following information: · On August 6, 2025, the VA was taken to the dentist but refused to get out of the vehicle so was not seen. On September 22, 2025, the VA was taken back to the dentist where it was decided that an operating room visit would be scheduled but that the appointments were scheduling six months out. On May 21, 2026, the VA had his/her annual comprehensive dental exam and pre-op assessment to prepare for dental work that was to be done under anesthesia on June 12, 2026. On June 12, 2026, the VA had oral surgery and the aftercare instructions included to brush the VA’s teeth twice daily. · The facility spoke to multiple staff persons who said that staff persons attempted to brush the VA’s twice daily, including while the VA took a bath in the morning because G1 told staff persons to “only” attempt to brush the VA’s teeth while the VA bathed because the VA would not “allow” his/her teeth to be brushed outside of the bath or shower. In the evening, staff persons also attempted to brush the VA’s teeth in the bathroom but the VA typically did not allow staff persons to do so and would “forcefully” push their hands away and said, “No,” repeatedly. Staff persons stopped when the VA became “too frustrated.” · Staff persons attempted to put the toothbrush in the VA’s mouth using a hand over hand technique but the VA typically said, “No,” and pushed staff persons hand away. G1 also told staff persons to count to 10 as they attempted which “often worked” but the VA still “refused” “multiple times.” The VA was “very strong” and could “easily prevent” staff persons from getting the toothbrush in their mouth. The VA would also splash the bath water on staff persons. When the VA displayed physical aggression towards others, staff persons usually stopped attempting at that time to prevent “further agitation.” · The VA had some “preferred” staff persons who were sometimes able to brush the VA’s teeth for 10 seconds but that was not “typical.” · The facility provided three separate daily hygiene logs that were from April 3 to 10, 2025; October 11 to 16, 2025; and April 7 to 14, 2026, showing times that staff persons attempted to brush the VA’s teeth and incidents of refusals. The D said that s/he had seen the VA since June 2023, and at that time, the VA had 4 teeth removed and 18 fillings, which was “worse” than in June 2026. (Note: This was prior to the VA moving into the facility.) The VA was seen in person every two years by the D and was sedated because the VA was “very aggressive.” The VA was also given medication to calm prior to going to the D’s office. The VA’s teeth had a “really high decay rate,” including due to the VA’s diet, which was a “big factor,” and the D said that Boost (nutrition drink) had a “lot” of sugar. The D “guessed” that it was “really hard” for staff persons to brush the VA’s teeth. At some point when the VA was at the D’s office, the VA was “aggressive and uncooperative,” even with having a medication to calm prior, and the VA “rushed out of the clinic” before the dental office “could do much.” The VA “still had quite a few [teeth] left” but after the appointment in June 2026, the D recommended that the VA be seen annually instead of every two years so that the “loss” was “a little more gradual.” The VA would have “a lot of cavities again if things stay the same.” The CM said that the VA had a history of dental concerns and refusing to brush his/her teeth but that the prior concerns were “not this extensive.” Staff persons documented when the VA refused to brush but the CM did not know what “attempts” were made to try to get the VA to brush. Due to staff changes, there was no “consistency” and the VA had a preference towards liking certain staff persons. When staff persons stopped working at the facility, it would cause a “domino” effect with the VA, including regarding the VA’s behaviors. The VA also had a “lot of anxiety” regarding going to the dentist so required sedation including for cleanings. Since the June 2026 appointment, the facility and the VA’s team implemented changes such as increased documentation regarding the VA’s oral cares, reducing a “high sugar” drink (Boost) that the VA drank daily, and reducing the number of cookies the VA ate daily. The Policy and Procedure on Health Service Coordination said that the facility was to implement procedures to ensure the continuity of care regarding health-related service needs as assigned in a client’s plans. Facility documentation showed P1, P2, P3, P4, and P5 were trained on the VA’s plans, facility policies, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: The VA’s support plans said that brushing the VA’s teeth was within the “scope” of services that the VA received at the facility and staff persons were to use hand over hand prompting to assist the VA with teeth brushing. The facility, G1, and G2 were to assist the VA in scheduling dental appointments.
On June 12, 2026, the VA had “12 fillings and 2 teeth pulled.” G1 said that this was caused by staff persons not brushing the VA’s teeth despite staff persons stating that they did so. Information was consistent from the VA’s plans, G1, the D, the CM, and staff persons that the VA had a limited amount of foods that s/he ate and those were “high” in sugars and the VA also drank juice, which “contributed” to the VA’s teeth decay. Information was also consistent from the VA’s plans, G1, the D, the CM, and staff persons that the VA had a history of refusing to brush his/her teeth and displayed physical aggression towards others while brushing the VA’s teeth. G1 said that the VA was also “really resistant” with him/her and G2 while brushing the VA’s teeth. G1 and staff persons each listed things to do to assist the VA with teeth brushing including counting, stacking the VA’s cares, or asking another staff person for assistance. Although there were concerns that staff persons did not brush the VA’s teeth and it was unfortunate that the VA had 12 fillings and 2 teeth pulled, given the aforementioned and that there were likely multiple factors that contributed to the VA’s dental concerns including that the VA had a history of refusing to brush his/her teeth and a history of dental issues including losing several teeth prior to moving into the facility; that when staff persons were successful in brushing, they could only brush the front of the VA’s teeth and often for a short time; and that there was no information that staff persons did not at least attempt to brush the VA’s teeth, there was not a preponderance of the evidence as to 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 added an outcome for the VA so that teeth brushing would be tracked daily. Staff persons were trained on assistance with brushing the VA’s teeth and documenting refusals consistently. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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