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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: 1072305-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy Heidi.Murphy@state.mn.us 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) provided cannabis to a vulnerable adult (VA) on several occasions. Date of Incident(s): Unknown dates between April and June 21, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on July 14, 2025; from documentation at the facility; and through seven interviews conducted with the VA, two facility staff persons (the SP, P2, and P3), facility supervisory staff persons (P1), the VA’s case manager (CM), and a facility resident (FC). The VA was not subject to guardianship. The VA enjoyed going for walks, playing with Legos, listening to music, and watching the news on television. The VA’s diagnoses included bipolar 2 disorder, post-traumatic stress disorder, other specified personality disorder, and unspecified psychosis not due to substance/known physiological condition. The VA had a history of substance use. The VA’s plans stated the VA had one hour of unsupervised time at the facility and two hours unsupervised time in the community. The VA’s plans also stated, “Staff should attempt to redirect [the VA] from substance use and contact the Crisis Float, if needed. Staff should also document the substance use on the behavior worksheets.” “Current marijuana use” was listed under “identified risks.” The facility was a one-story house in a residential neighborhood with a finished basement. There was a living room, kitchen, three bedrooms, and bathroom on the main level. The basement had an open living space, a bathroom, bedroom, furnace room, and laundry room that also served as the office. The facility’s Internal Review stated the VA told P2 “one day a while ago” the SP “lit up a blunt” and offered it to the VA. The VA accepted. The SP began bringing the VA marijuana on a regular basis, most recently June 21, 2025. The SP then asked the VA for money for the marijuana and stated it was a “transaction.” The VA told the SP s/he did not have the money and the VA would not have taken the marijuana if the VA would have known it was not a gift. The VA then reported the incident to the facility. The SP did not participate in an interview with P2. The VA provided the following information: · The VA had substance use issues. The VA left the facility to smoke marijuana and the VA was told to smoke the marijuana at the facility outside to prevent the VA from leaving without supervision. The VA stated the use of marijuana was for “harm reduction.” · The SP “helped [the VA] out” by sharing “weed” when the VA was stressed out. The VA felt it was not good boundaries for the SP to have given the VA marijuana. · The first time the SP gave the VA marijuana at the facility was on an unknown date in April or May of 2025. The SP lit a “blunt” and handed it to the VA. The VA did not ask for the blunt. The two smoked the marijuana blunt together. · The SP “always” left marijuana out on the deck for the VA. The SP told the VA s/he left the marijuana for the VA and would say, “I got something for you underneath the deck. Go get it,” or “I left something under the stool for you.” The VA stated it happened less than 10 times. The VA would not have taken the marijuana if the VA knew it was a “front thing” (when goods were accepted and the giver expected payment at a later time). · The VA overheard the SP’s speaker phone conversation with a prior staff person (PS) who used to work at a different facility the VA had been a resident at. The VA recognized the PS’s voice and said, “Hey [PS].” The SP asked the PS if s/he heard the VA and that the VA said, “Hey [PS].” The VA stated the SP and the PS were “talking really bad” about the VA. The VA thought s/he had a good relationship with the SP until the VA overheard the phone call. · The SP never told the VA s/he expected money for the marijuana or mentioned that the marijuana was “fronted.” The VA stated when the SP was on the phone with the PS, “it sounded like that’s what [the SP] was expecting.” The SP stated something similar to, “I fronted [the VA] a ten, then [s/he] gave me it back, then I kept fronting him.” · The VA gave the SP marijuana one time for “helping [the VA] out.” · The VA was “triggered” by the conversation the SP had with the PS. The VA also stated one night while s/he walked back to the facility from a nearby store, the VA felt s/he was followed by a car. When the car passed the VA, the VA believed s/he heard the voice of the PS. The VA did not like that and reported the marijuana incidents. The VA did not recall when the incident with the car occurred. · The SP sent the VA a text message that said, “You got me fired, don’t ever call this number again.” The VA then blocked the SP. The VA did not have access to his/her phone at the time of the interview. · The VA was unaware if the SP had given any other residents marijuana and did not believe anyone else was aware the SP gave the VA marijuana. The SP provided the following information: · On June 22, 2025, the SP got a call from P1. P1 asked if the SP knew the PS. The SP confirmed that s/he knew the PS and that the PS worked at another facility within the company. P1 told the SP that the VA knew the PS and to monitor what was said to the PS because the VA was listening. On June 23, 2025, P1 called and told the SP s/he was suspended. · The VA called the SP on June 25, 2025. The SP texted back on June 26, 2025, and told the VA s/he was fired and to not call or text. The SP provided the text conversation to this investigator. The SP texted the VA and said, “You got me fired [the VA] for lying on me,” and “Can’t be texting or calling me anymore.” The VA responded, “Nobody got you fired yourself and I’m being honest with you I didn’t say anything however there’s three other people here who didn’t like that either.” · The SP stated the VA had his/her phone number from an incident in which a supervisor asked the SP to pick the VA up. The SP called the VA to get the VA’s location. The SP denied there was any other phone communication with the VA until the SP no longer worked at the facility. · The SP did not have much interaction with the VA. The VA mainly stayed in his/her room. The SP stated s/he never smoked marijuana with the VA, did not give the VA any marijuana, and did not leave marijuana for the VA. The VA never asked the SP for marijuana. The VA smoked marijuana since the SP started working at the facility. · The SP made phone calls outside, away from the VA and other residents. The SP stated s/he did not have a conversation with the PS about the VA. P1 provided the following information: · On June 24, 2025, P1 called and told the SP s/he was suspended and that P1 would call later to set up a meeting. Two hours later, the SP texted P1 and resigned. · It was “hit or miss” when the VA made reports. There had been “a lot of inaccurate reporting, but also some accurate reporting too.” · The VA told P1 that the SP had smoked marijuana and offered some to the VA. The SP and the VA smoked the marijuana together. The SP gave the VA marijuana and the VA gave the SP marijuana back. The SP told the VA that s/he owed the SP money because the SP “fronted” the marijuana to the VA. The VA told the SP that the SP gifted it to the VA. P2 provided the following information: · The VA was a “very difficult individual to work with.” The VA had a history of not providing reliable information. · The VA told P2 the SP was outside cleaning the grill, lit up a “blunt,” and shared the blunt with the VA. After that, the SP started bringing marijuana and shared it with the VA. · The SP had not returned P2’s phone calls and did not provide any information for P2’s investigation. The CM provided the following information: · The CM learned about the alleged incident from P1. The VA had not told the CM about it, “which was odd.” · The VA used marijuana “frequently.” The VA was good at “getting close to staff” and “then the lines get blurred.” · There had been “inaccuracies” in information the VA has provided in the past. “There’s always some truth, details and intentions are different. Involvement can be a little bit different.” P3 provided the following information: · The VA had provided inaccurate information in the past to get attention from his/her CM. The VA changed his/her mind and “sometimes [the VA] says the truth and sometimes [the VA] does not.” · The SP “interacted mostly with [the VA]” and got along with the VA more than other staff persons. P3 did not hear any conversations about marijuana or about the exchange of marijuana between the VA and the SP. · P3 never had any concerns with the SP. The FC provided the following information: · The FC did not have any concerns with any staff persons and felt they all did more than their job duties. The FC liked the SP and felt the SP “went above and beyond [his/her] job title.” · The FC never saw any staff persons use marijuana at the facility or give marijuana to any of the residents. Facility documentation showed that all staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was trained on the facility’s policies on drugs and alcohol and Employee Conduct Expectations. The SP was not trained on the VA’s plans. Conclusion: Information showed that the VA told P1 and other supervisory staff persons at the facility that the SP and the VA smoked a blunt together and the SP gave the VA marijuana. The VA overheard the SP’s phone conversation with the PS, and thought the SP told the PS that the SP “fronted” the VA the marijuana. The VA provided inconsistent information regarding whether the SP asked the VA for money for the marijuana. The SP denied that s/he ever smoked marijuana with the VA or provided the VA with marijuana. The FC and P3 had no concerns with the SP and had not witnessed the SP smoke marijuana or provide marijuana to the VA or any other resident. Although the VA stated that the SP gave him/her marijuana and the VA had a history of substance use, given that the VA had a history of not providing accurate information, that the SP denied doing so, and that there were no witnesses or further information to confirm or dispute the SP’s or VA’s information, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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 Internal Review found the policies and procedures were adequate and were not followed, there was not a need for additional staff training, the event was not similar to past events with the adult or services involved, and there was a need for corrective action by the license holder to protect the health and safety of the vulnerable adult. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On November 7, 2025, the facility was issued a Correction Order for not having documentation or information whether the the SP was trained on the VA’s plans.
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