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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: 1106764 -H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery elisa.montgomery@state.mn.us 651-431-6474 Suspected Maltreatment Reported: It was reported that a vulnerable adult’s (VA) debit card information was used by an unknown individual without the VA’s knowledge on multiple occasions from November 2024 to October 2025. Date of Incident(s): Multiple dates from November 2024 to October 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 9, paragraph (b), clause (1): In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 29, 2025; from documentation at the facility; financial records; and through five interviews conducted with a supervisory facility staff person (P1), the VA’s case manager (CM), the VA’s guardian (G), the VA, and the VA’s family member (FM). P2 who was a former supervisor of the facility in 2024, was contacted to request an interview but P2 did not respond. The VA enjoyed bowling, being out in his/her community, and going on airplanes to visit out of state family members. The VA was diagnosed with mild intellectual disabilities and epileptic syndrome. Due to the VA’s diagnoses, the VA was not able to manage his/her finances independently and required a Representative Payee to assist with his/her financial management. The Individual Abuse Prevention Plan provided the following information: The VA was susceptible to financial exploitation and was not able to handle his/her own financial matters. Staff would provide hands-on supports with managing the VA’s funds. Staff assisted the VA with weekly reviews of his/her check ledger for accuracy and with balancing his/her checkbook with bank statements once per month. The VA kept cash, ID card, and debit card on his/her person or in his/her wallet. The VA’s checkbook was kept in an individual lockbox in the staff office. The Financial Authorization dated February 6, 2024, and was signed by the G provided the following information: The VA needed assistance from the facility with cash resources and funding for his/her services received at the facility; assistance from the facility with management of his/her checking account, including using an ATM or debit card, and managing his/her checkbook/bank account; and with management of gift cards and “tracking transactions.” The VA had a Representative Payee provided by the facility. The VA provided the following information: The VA always kept his/her wallet on his/her person or in his/her bedroom. Staff would assist the VA with writing checks and cashing checks at the bank. The VA had a debit card in the past, but did not remember when s/he had last used a debit card. The VA would carry cash but was not able to recognize the value of the cash that s/he had. The VA did not recall if s/he had ordered food but recalled going to restaurants and/or fast-food establishments. The VA did not have a cellphone and/or tablet and did not know how to use the internet. Due to the VA’s limited knowledge of his/her finances, the VA did not have information regarding the incident(s). The CM provided the following information: · The CM was aware that there were unauthorized charges on the VA’s debit card through UberEats™ [an online food ordering service] in September and October of 2025. The VA did not have the ability to setup or manage an UberEats™ account as the VA did not know how to use technology like a smart phone or computer. · There were concerns regarding frequent turnover in the supervisory position of the facility and that the CM had signed documents multiple times due to frequent turnover or documents being lost. · The G was in the process of becoming the VA’s Representative Payee due to concerns regarding the facility’s ability to adequately perform the Representative Payee services that the VA required. · The CM did not have concerns with the current supervisory staff person that began working at the facility in February 2025. The G provided the following information: · The G did not have access to the VA’s bank statements but received a call from the FM regarding possible charges on the VA’s bank account in November and December 2024. The FM and the G discussed getting the VA a new debit card and the FM halted the VA’s bank account in December 2024 and ordered a new debit card. · In December 2024, the G contacted the facility supervisor at the time (P2), regarding the charges for UberEats™ and one charge from Macys.com. The facility supervisor ensured that s/he would look into the charges but then resigned from his/her position. · After P2 resigned in December 2024, there was high turnover in the facility supervisor position, and it was unknown if the facility supervisor knew who was using the VA’s debit card information. No other charges appeared at that time on the VA’s account after the P2 resigned and the VA was not reimbursed for the unknown transactions that occurred in November and December 2024. · The G was contacted again by the FM regarding charges for UberEats™ in October 2025. The FM and G agreed to cancel the VA’s debit card to limit further charges as it was unknown who had added the VA’s debit card to an unknown UberEats™ account. Another new debit card was ordered and sent to the VA. · The G was in the process of obtaining Representative Payee for the VA. To the G’s knowledge, the VA was not reimbursed by the facility regarding the missing funds. The VA would not have the ability to use UberEats™ or be able to order from Macy’s online as s/he did not know how to use a computer or the internet. The FM provided the following information: · In December 2024, the FM checked the VA’s bank account statement and noticed charges for UberEats™ in November and December 2024. The FM contacted the CM and P2 who was working at the facility at the time. · Shortly after the FM contacted P2 in December 2024, P2 resigned and no longer worked at the facility. The FM was not notified if the facility was able to determine where the UberEats™ charges had come from, and the VA was not reimbursed. · In October 2025, the FM saw charges for UberEats™ on the VA’s bank statements again and “shut off” the VA’s debit card and then cancelled the debit card. The FM contacted the G and the CM regarding the charges, and it was determined that the VA would no longer use a debit card since s/he primarily used small amounts of cash. · The VA would not have the capacity to setup an UberEats™ account and would not understand if a staff person assisted the VA with setting up an account. The VA did not know how to use the internet or order food by other means. · To the FM’s knowledge, the VA had not been reimbursed by the facility and that the G was working to become the VA’s Representative Payee. · The FM had concerns regarding high turnover with the facility supervisor position and had concerns that there was not much done regarding the VA’s charges on his/her bank account through UberEats™. P1 provided the following information: · P1 had been working at the facility since April 2025. P1 was aware that there were charges made on the VA’s bank account for UberEats™ and Macys.com sometime in 2024 and believed that the VA would not have been able to make those purchases independently. · When P1 began working at the facility, the staff office where the VA’s checkbook and ledgers were located was disorganized and it was difficult to determine who was overseeing the VA’s funds. · All staff persons would have access to the VA’s debit card since staff persons at the facility would assist the VA with making ATM cash withdrawals, making purchases with his/her debit card in stores, and assisting the VA with making cash purchases in stores. · A meeting was held with the FM, the CM, the G, and P1 in August 2025 and it was determined that P1 would send bank statements, bill statements, cash withdrawal receipts, and spending receipts on a weekly basis to the CM and G. · P1 did not have concerns that current staff persons had used the VA’s debit card information and to P1’s knowledge, staff person’s currently working with the VA had not worked with the VA in November or December 2024. The VA’s Bank Statements provided the following information: UberEats™ was purchased on the following dates: · November 22, 2024- totaling $19.38 · November 25, 2024- totaling $15.88 · November 26, 2024- totaling $15.82 · November 29, 2024- totaling $16.04 · November 29, 2024- totaling $20.62 · November 29, 2024- totaling $23.94 · December 2, 2024- totaling $57.49 · December 2, 2024- totaling $32.32 · December 3, 2024- totaling $29.88 · December 4, 2024- totaling $23.25 · September 26, 2025- totaling $43.51 · September 29, 2025- totaling $26.29 · September 29, 2025- totaling $33.78 · October 2, 2025- totaling $23.23 Macys.com was purchased on the following date: · November 29, 2024- totaling $57.50 It was also found that there were charges for Lyft™ (a transportation service) on the following dates: · November 25, 2024- totaling $9.00 · November 27, 2024- totaling $9.38 The total amount of debit card transactions was $457.31. No receipts were found regarding the transactions and ledgers from the facility did not reflect charges that were made on the VA’s debit card for November and December of 2024 and September and October of 2025. The last four digits of the VA’s debit card appeared next to the transactions and the number was different for the 2024 and the 2025 purchases. All staff persons interviewed received training regarding the VA’s plan of care and how to track finances, as well as the facilities policies and procedures and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information provided from P1, the FM, G, and CM was consistent and identified that the VA did not have the ability to use UberEats™ or Macys.com and that the charges reflected on the VA’s bank account were not accurate with the VA’s purchases in facility records. The VA’s Individual Abuse Prevention Plan identified that staff persons working with the VA provided hands on supports to the VA regarding funds. The G, FM, and CM were concerned about the frequent turnover of the supervisor position and that after they told P2 about the charges, P2 resigned. No staff who worked when the November and December 2024 purchases were made still worked at the facility when the September and October 2025 purchases were made. In addition, the last four digits of the VA’s card that was used to make the purchases were different in 2024 than in 2025. Given that all staff persons assisted the VA with purchases and ATM withdrawals and had access to the VA’s card which the VA kept on his/her persons and that consistent information showed that the VA would not have the ability to make the purchases on his/her own, there was a preponderance of the evidence that the VA’s funds were used in the absence of legal authority. It was determined that financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). 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. Given that the facility was responsible for the financial management of the VA’s funds, that multiple staff persons worked when the 2024 and 2025 purchases were made, that the card number used differed between the 2024 and 2025 purchases, and that all staff persons had access to the VA’s card, it was not determined who used the VA’s card or whether it was used by more than one person. Therefore, there was inconclusive responsibility for the financial exploitation of the VA. Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate. It was noted that it was more likely that the VA had not made online purchases using his/her debit card. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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