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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: 1125543-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth 651-431-6537 Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding the cleanliness of a vulnerable adult’s (VA’s) bedroom. This included that the VA’s bedroom smelled of urine, that the VA’s bedding was soiled with urine, and concerns of hoarding. Date of Incident(s): Ongoing and prior to August 31, 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 September 14, 2026; from documentation at the facility; and through five interviews conducted with the VA, two facility supervisory staff persons (P1 and P2), a staff person (P3), who provided positive behavioral supports, and the VA’s case manager (CM). Additionally, attempts were made via phone and email to contact and interview three staff persons (P4, P5, and P6) but the attempts were not successful. The VA was not subject to guardianship. The facility was a one-story home with a finished basement. A staff office, the VA’s bedroom, another client’s room, and shared living area, bathroom, and laundry room were in the basement. The VA was diagnosed with major depressive disorder, intellectual disability disorder, post-traumatic stress disorder, borderline personality disorder, and mild developmental disability. The VA also had ulcerative colitis. The VA enjoyed shopping and art. The VA’s Positive Behavior Support Plan, the Risk Assessment Detail, Support Plan, the ISSA Assessment Detail, and two untitled documents provided the following information: · The VA had a history of hoarding or “possession-protective behavior.” The VA searched the garbage for discarded items and brought unsanitary items into the facility. The VA retained items that were expired, soiled, broken, or no longer usable and refused to throw things away when prompted by staff persons causing “unsanitary” issues. The VA also kept “old” food in his/her room. The VA had a history of obtaining items and placing them in his/her room to the point where it was fire hazard. · The VA was most likely to engage in hoarding/possession-protective behaviors when staff persons cleaned or organized his/her room or staff persons suggested discarding the VA’s possessions. The VA became “distressed” regarding the movement, organization, disposal, or perceived loss of belongings. At times, the VA may become highly focused on protecting his/her possessions and yell or become physically aggressive. The VA often refused cleaning efforts so staff persons were to build positive relationships with the VA, promote choice and independence with housekeeping responsibilities, and break larger tasks into manageable steps. Staff persons were to provide advance notice before transitions including room cleaning activities and were to remind the VA of the importance of maintaining the cleanliness of his/her room. Staff persons were to use a calm voice when speaking to the VA.
· The VA was to throw trash in the garbage “right away” and once a week, the VA was to spend at least five minutes filling a 13-gallon trash bag with items to discard with assistance. Staff persons were to prioritize items to get rid of that posed significant health and safety risks such as perishable foods. Nothing was to be removed without the VA’s presence and permission unless it posed a “significant health or safety hazard.” Staff persons were not to go in the VA’s bedroom without permission or when the VA was not there. The VA had “trust issues” in the past from people throwing his/her belongings away. · When shopping with the VA, staff persons were to remind the VA that if s/he chose to buy an item, s/he needed to discard an item of the same size/shape. The VA needed daily and “constant support” from staff persons to work on organizing and getting things cleaned that had “odors.” · The VA had a goal to live independently and improve his/her organization and cleanliness. The VA liked his/her home environment “clean and comfy.” · The VA also had a history of having urinary incontinence on his/her clothing, bedding, and other surfaces “outside of the toilet” and the “clutter” in the VA’s room tended to “hold the smell of urine.” The incontinence often occurred during the night, so the VA wore an adult undergarment. (Note: Information from staff persons showed that the VA did not wear an adult undergarment.) The VA was working on cutting back on liquids at night. The VA also had a history of sleeping in soiled bedding for “days.” The VA may also have incontinence of the bowel which occurred during an ulcerative colitis flareup. The VA required some prompting with bathing but could do so independently. · The VA did his/her own laundry with reminders to put his/her clothes away and wash his/her bedding as needed. The VA was to ensure s/he had clean clothes to wear and clean bedding to sleep in each night and staff persons were to offer reminders for task initiation and task completion. The Replacement Behavior Outcome said that staff persons were to provide the VA with routine restroom opportunities throughout the day to reduce incidents of urinary incontinence, refusals or delay of toileting routines, urination in inappropriate locations, prolonged exposure to wet clothing, and sanitation concerns within shared environments. If urinary incontinence occurred, staff persons were to remain calm and neutral and address hygiene “promptly.” The Maintaining Living Environment Goal said that the VA was to keep his/her living space clean by organizing and decluttering his/her belongings on a daily basis. Staff persons were to approach the VA daily and remind the VA of the importance of keeping his/her room clean. Staff persons were to ask the VA each morning to put his/her sheets and bedding in the wash. If the VA refused, staff persons were to tell the VA that they were going into his/her room to wash the VA’s sheets and bedding while the VA was at work. (Note: The VA was not currently working.) Once the VA returned from work, staff persons were to give the VA time to wind down and then “scan” the VA’s bedroom for any food items that needed to be removed. If the VA refused, staff persons were to remove the items. Staff persons were to also assist the VA with cleaning his/her room and if the VA refused, staff persons were to provide verbal prompts. Staff persons were to document whether the VA completed these tasks. If the VA refused for three consecutive days, staff persons were to notify the program supervisor who notified the program director and/or area director and then a meeting was to be arranged with the VA and the supervisory staff persons. A letter from the facility to the VA dated March 15, 2019, provided the following information: · The facility had concerns regarding the VA’s bedroom and “several health and safety issues” which needed to be “addressed.” This included items in the VA’s bedroom making the room “unsafe” to walk in and that blocked fire exits and a smell of urine. · Because of the concerns, the VA’s room needed to be “cleaned and decluttered to comply with the community residential services licensing requirements.” Garbage in the VA’s room was to be discarded and dirty clothing and bedding was to be washed. The facility “encouraged” the VA to pick up trash and empty his/her trash daily; pick up dirty clothing and wash it weekly; wash bedding and replace it weekly; dust/wash all surfaces weekly; vacuum and sweep the floor weekly; and organize the closet and drawers bi-weekly. If the VA chose not to assist, staff persons would complete those tasks for the VA. The facility replaced the flooring in the VA’s bedroom and ordered a storage pod paid for by the facility for one month while the room was deep cleaned. · Going forward, “criteria” such as the facility being free from the “accumulation of dirt, rubbish…or insects” was to be met and the VA’s case manager had been notified and was in “agreement.” (Note: This was a different case manager than the CM because the CM was not working with the VA at that time.) · It also noted that prior attempts to keep the VA’s room clean, including “reinforcement programs” and a “living environmental plan” had not been “effective in addressing hoarding behavior.” At some point, the VA had an occupational therapist that specialized in hoarding that was not successful. The VA had an outcome to address cleanliness for “several years with no success.” The facility had met with the VA “on and off for many years” and had not found “any strategies” that were effective in addressing “hoarding and cleanliness.” According to the VA’s Psychiatric Referral Form dated August 25, 2026, the VA’s “hoarding/cleanliness” had increased. The VA was to continue his/her medications as prescribed. The CM provided the following information: · In August 2026, the CM was at the facility for the VA’s annual meeting and described the VA’s bedroom as “horrendous.” Additionally, the smell of urine was “intense.” P1 and P2 were also present and P2 could not stand in the VA’s bedroom without covering his/her nose and mouth and the CM’s eyes and throat “began to burn within a minute from the smell of urine.” The CM had “serious” concerns regarding the health and safety of the VA, staff persons, and other clients including that they were breathing in ammonia and other “potential bacteria” from the urine. P1 told the CM that the urine was in the walls and flooring and that they could not get rid of the smell. P1 further told the CM that at some point, the facility purchased a new mattress for the VA but the CM saw that it was “soiled” with urine and had some fecal matter. The VA’s bedding was also soiled with urine and the CM could tell that the bedding had been like that for “multiple days” because it was “soiled.” P1 and P2 said that they cleaned the VA’s bedroom over the weekend but the CM was there on a Monday and the CM did not know if they were being “truthful” due to the “smell and condition.” · During the annual meeting, there were flies nearby the VA and the CM did not think that the VA had showered for a “few days.” Staff persons were to prompt the VA to shower but the VA “had to be willing to do it,” otherwise s/he would not. · The VA had a history of incontinence of his/her bowel and bladder, including while in his/her bedroom, and “struggled” with cleaning the incontinence. The VA also had a history of “hoarding” and had been “kicked out” of prior programs due to the concerns. The CM had concerns that the facility “should be doing more” and that they were not maintaining a clean or safe environment for the VA. However, it was “hard” because the VA would not consistently let staff persons help him/her and staff persons could not “force” clients to do things. Additionally, after staff persons assisted the VA with cleaning, the VA would “dig things out” of the garbage and bring the items back to his/her room. The VA was his/her own guardian but was not “making the best choices.” The CM did not know if staff persons were documenting when they attempted to help the VA clean and “part of the struggle” was staff turnover. Additionally, staff persons stopped working at the facility due to the concerns. · The facility and the VA’s team tried multiple things prior including dialectical behavioral therapy but the VA was not “willing to participate.” The VA also had a “hoarding specialist from 2022 to 2025 but it was not “very helpful.” The VA did not want to attend therapy which was a “roadblock.” The facility also had a storage pod to help keep the VA’s room clean. The VA currently had “positive supports” with P3 but there was “no change.” The VA provided the following information: · The VA described his/her bedroom as a “disaster” and said that s/he “tried” not to have it that way but that it was “kind of hard” including because s/he was “messy.” The VA knew it was a “tripping hazard” to not have his/her bedroom clean but said that cleaning it was “overwhelming.” The VA wanted staff persons to help him/her be more organized and “eliminate clutter” but that was “kind of hard.” · Staff persons asked the VA if they could help clean and “sometimes” assisted the VA with cleaning but the VA had “anxiety” when staff persons assisted. It “varied” depending on which staff persons the VA felt comfortable assisting with cleaning his/her room. The VA said that P2 “cleaned everything from head to toe” but the VA did not “like that invasion of privacy” but knew it “had to be done.” Additionally, some staff persons were “lazy,” but those were “old” staff persons who no longer worked at the facility. A former staff person at another facility, who the VA did not name, threw away the VA’s belongings and the VA was “not so happy with them” and said that it was his/her “property.” · The VA washed his/her own laundry and bedding but “sometimes” had help. The VA “normally” slept with sheets but not “all the time” including because s/he fell asleep before putting them on. The VA kept extra sheets in his/her dresser or laundry basket. · The clients were not supposed to eat in their bedrooms because it could cause “bugs like there are now,” which the VA said were “two” flies in his/her room and that staff persons had a device to help eliminate them. Staff persons “tried” to help the VA take trash out of his/her room. The VA “handled” his/her own hygiene tasks and had enough supplies on hand for both showering and laundry. P3 and the Monthly Community Behavior supports Update written by P3 provided the following information: · P3 began working with the VA in approximately May 2026, to work with the VA on hoarding and incontinence concerns. From May to August 2026, the VA’s hoarding and possession protective behavior decreased. The VA “demonstrated positive participation” in household activities on “several occasions” including “accepting” staff persons assistance with cleaning and laundry and independently putting away clean clothing. However, maintaining the VA’s bedroom and laundry “continued” to be an area where the VA needed support. There were “several instances” documented where the VA refused assistance with cleaning his/her room or assistance with laundry, including an incident in August 2026 where the VA had “soiled” laundry and refused staff assistance with cleaning. · P3 was to continue in person observations, review behavioral data, provide training and support, and “consult” with the VA and staff persons. The VA was to focus on hygiene and maintaining a sanitary living environment. Staff persons were to address anything that was “unsanitary and unhealthy” first and were to continue involving the VA in decisions involving his/her bedroom, laundry, and personal belongings by offering “appropriate choices” about when and how tasks were completed. Staff persons were to ask the VA “regularly” to help clean. Staff persons were to also break larger cleaning tasks into smaller steps and “clearly identify” which belongings were to be moved, cleaned or discarded, which may “reduce concerns” regarding staff persons handling of the VA’s possessions and increase participation. It noted that concerns about staff persons handing the VA’s personal belongings may “contribute resistance” during participation with cleaning or laundry. Positive participation in cleaning and laundry should be reinforced. Staff persons should provide the VA with “consistent” expectations for laundry and bedroom cleaning and provide opportunities for the VA to provide in each task. · At some point, P3 did a training at the facility for the aforementioned suggestions but there were “not a lot of staff there.” However, the staff persons had access to those plans. P3 did not have any concerns regarding staff persons and said that they “offered” to help clean. At some point, the facility also had a “hoarding specialist” due to the concerns. · P3 typically met with the VA upstairs and was not “frequently downstairs” but s/he could smell a “urine odor.” P3 was in the facility once a week and since s/he started, things were “about the same” and not “worse.” The VA had sheets on his/her bed but the bed was “covered” with the VA’s belongings. P3 saw fruit flies but no other bugs or rodents. P3 had not seen the VA in soiled clothes. P1 and P2 provided the following information: · The VA had a history of similar concerns and prior to moving to the facility, the VA’s apartment had been “condemned.” While at the facility, the concerns were “ongoing” and the VA worked with a “behavioralist” and had a “hoarding specialist,” but the VA chose not to participate and only threw away a “Kleenex.” At some point, the facility got a storage pod and the VA also had some of his/her belongings in a storage unit and the facility garage. In the past, the VA also had a rewards program where the VA earned things s/he enjoyed but the VA only did it “one day.” The VA had multiple case managers over the years who were all aware of the concerns. The facility also hired a clearer once a week to do “deep sanitizing.” Additionally, the VA saw a psychiatrist who was aware of the concerns. The VA took his/her medications as prescribed and had a PRN medication that s/he could take prior to staff persons cleaning but the VA did not consistently take it. · When staff persons asked the VA to clean, the VA would get “very upset” and state that s/he was his/her “own guardian” and did not need to clean his/her room. The VA had a history of blocking his/her room and would not always let staff persons in. Staff persons did not know how to approach the VA when s/he refused or would not let staff persons in his/her room so P3 trained staff persons on that. Staff persons also talked to the VA and after a “few hours” the VA would “process it” and often allow staff to help. · Each day when P2 arrived around noon, the VA was still in bed sleeping and was “soaked” in urine, which was daily. P2 prompted the VA to get up but the VA would become “really mad” and “kick” P2 out of his/her room. P2 would then leave but try again later and then the VA was “ready to get up.” The VA also needed “coaxing” to shower and P2 told the VA to “shower” the urine off and that the urine would “burn” the VA’s skin but the VA would “get upset” with P2. P2 also offered to help clean the VA’s hair and back but the VA “refused.” · There was a bathroom near the VA’s bedroom but the VA did not want to get up during the night and would “rather go” to the bathroom while in bed. The VA had seen a urologist but “nothing was physically wrong” and the VA said that s/he was “too lazy” to get out of bed. Because of this, the VA’s “whole room” smelled like urine so P2 would “deep clean” the VA’s room “at least” three times per week. The VA had adult undergarments but did not want to wear them. The facility suggested that the VA get a portable toilet for his/her bedroom so it was “easier” for the VA during the night but the VA “declined.” Staff persons tried to assist the VA with throwing away items that were “urine soaked” but the VA would take them out of the garbage. The VA also did not always want to wash things that had fecal matter on them so staff persons put the items in a bag in the garage and told the VA that when s/he was “ready,” they would help the VA clean it. · P2 washed the VA’s bedding daily and also wiped down the VA’s mattress pad which was plastic. P2 then put the bedding back on once it was dry but said it took “a lot of coaxing” and that the VA would get “upset.” The VA was “capable” of doing his/her own laundry but would “not do it” so staff persons would. The VA also had more than one set of bedding but P1 said that the VA did not like to use sheets. P2 “tried” to keep the VA’s room clean and smelling “good” but it was “nearly impossible” because the VA “would not cooperate.” P1 purchased something for the urine on the clothing and bedding to help get rid of the smell. At times, the facility had four to five staff persons take “every single fabric item, “including stuffed animals,” to a laundromat to wash them. P2 also mopped the VA’s floor daily and washed the walls and after, the VA’s room no longer smelled. However, the following morning when s/he returned, it was “horrible.” · The VA’s bedroom was “always packed with stuff” and the VA did not want to throw things away.” P2 told the VA that this was a “safety hazard” but it was “very difficult” to clean the VA’s bedroom if the VA “did not want you in there.” Additionally, the VA’s friends and family members often brought items to the VA and recently brought larger items including a “bassinet.” · The VA would “never” take out his/her trash, despite being “capable,” and staff persons would need to do so. The VA also stored food under his/her bed which would “mold” and P2 would “get it out of there.” Staff persons would get the VA’s bedroom clean where there were no “gnats” but later there would be some and they would find “boxes of food” under the VA’s bed. A “couple weeks prior,” the VA ordered “ten boxes” of food from a nearby fast-food restaurant after the asleep overnight staff person went to bed. · The VA also had “a ton” of flies in his/her room but once the VA’s bedroom was “cleaned up,” they would “dissipate.” The facility also had a device to remove the flies. (Note: At the time of the site visit, this device was not plugged in and there were multiple flies in the lower-level including the VA’s bedroom.) P2 never noticed any mouse droppings or any other insects besides fruit flies which typically only came if there was “fruit going bad” upstairs in the kitchen. · Staff persons documented when they assisted the VA with cleaning his/her room or when the VA refused. P2 did not have any concerns with staff persons regarding helping the VA and said that “all staff tried to help.” · Because of these concerns, staff persons stopped working at the facility and said they were “getting sick from the smell.” At times, P2 needed to step outside to get “fresh air” because the smell was “burning” his/her eyes. Another staff person became “nauseated” so needed to “leave.” P1 said that the facility office was also connected to the VA’s bedroom via a vent and staff persons would get a “headache” when in the office. If P1 was at the facility an “entire” day, s/he would be coughing because it affected his/her “lungs.” Another staff person said that s/he would not go in the VA’s bedroom because it was “hazardous” so the facility purchased “hazard suits” for staff persons. The other client in the lower level would “complain” about the smell. (Note: As of October 2026, there was no client residing in the other bedroom on the lower level and the client moved out unrelated to the concerns.) The VA’s health was “pretty good” and the VA said that s/he had “no health concerns” due to the concerns. However, P2 said that the skin above the VA’s navel was “starting” to get an open sore due to the incontinence so P2 told the VA that s/he needed to keep his/her skin “clean.” However, P1 did not know if it was from the incontinence or other factors but P1 told the VA that s/he needed to shower because fecal and urinary incontinence were not good for his/her skin. · The CM saw the VA’s bedroom after the VA’s annual meeting in August 2026 and said the bedroom was “really bad” but P1 said it was “really good” and that they had cleaned it prior with three staff persons. P1 said there was a “path” in the VA’s room and that there was not typically a “path” for the VA to walk. The CM suggested that the VA get a mental health case manager which the VA agreed to but after looking into it, the VA did not “qualify.” On September 14, 2026, this investigator went to the facility unannounced and observed multiple flies in the VA’s bedroom and adjacent basement living room. The VA’s recycling container was full and the VA had a pizza box and open bag of chips, along with other items covering most of his/her flooring and furniture. There was an air purifier in the VA’s room. The VA’s bedding was also not on his/her bed. A staff person told this investigator that the bedding was being washed but there was nothing in the washer or dryer. This investigator could also smell urine in the VA’s bedroom and nearby office. Facility documentation showed that all staff persons who worked with the VA, including P1 and P2, were trained on the VA’s plans. P1, P2, and P3 were also trained on facility policies and procedures and on the Reporting of Maltreatment of Vulnerable Adult’s Act. Conclusion: The VA had a history of refusing to complete basic hygiene including maintaining a clean bedroom, showering, and cleaning him/herself after incontinence within his/her bedroom. The VA also had a history of hoarding. Facility documentation, the CM, and P1-P3 said staff persons attempted to work with the VA on cleaning his/her bedroom, throwing items away including those that were soiled, doing laundry, and his/her hygiene, but the VA often refused. The facility had been unsuccessful in multiple attempts to get the VA to engage in outside services to help with these concerns. Additionally, the facility was using a staff person who provided positive behavioral supports in the facility to develop a plan for the VA and staff persons and also hired a cleaning person weekly who “deep sanitized.” Based on the observation and statements from the CM, P1-P3, and this investigators visit, the smell and condition of the VA’s bedroom was a concern, including the flies in the shared living area, and the Department issued a recommendation that the facility ensure consistency with a person’s protection-related rights, as indicated in Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clauses (8) and (9), to include the right to have a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects, and free from hazards that threaten the person’s health or safety. However, the facility and staff persons attempted to work with the VA as s/he engaged in ongoing lack of self-care. Given the aforementioned, there was not a preponderance of the evidence whether there was a failure to provide the VA with care or services that were reasonable and necessary to maintain his/her physical 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. It noted that over the years, the facility replaced “several mattresses” and bedding and installed hospital grade flooring in the VA’s room in addition to other things that were noted above that were put in place to help the VA. The VA’s ISSA and Behavioral Support Plan were updated to include concerns with incontinence and hoarding and proactive strategies and staff persons were trained on the VA’s updated plans. Action Taken by Department of Human Services, Office of Inspector General: On November 4, 2026, the facility was issued a Recommendation as outlined in this report.
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