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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: 1073635-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns/Alice Percy 651-431-2000 Suspected Maltreatment Reported: Allegation one: A staff person (SP) took a vulnerable adult (VA) to a smoke shop, where s/he purchased tetrahydrocannabinol (THC) gummies. The VA then overdosed on nearly 3,000 milligrams (mg) of THC and was admitted to an emergency room for stabilization. Allegation two: It was also reported that the SP took two of the THC gummies from the VA’s pack of gummies. Allegation three: During the course of the investigation, it was reported that the SP called the VA “heavy” and told him/her to spend more time at the gym. Date of Incident(s): Allegations one and two: August 10 - 11, 2025. Allegation three: Unknown date(s). 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); and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 October 29, 2025; from documentation at the facility and medical records; and through seven interviews conducted with two facility supervisory staff persons (P1 and P2), a staff person (P3), the VA’s therapist (T), the VA, the SP, and the VA’s case manager (CM). The VA enjoyed listening to music, running, camping, fishing, cross country skiing, cooking, and spending time with friends and family members. The VA’s diagnoses included anxiety, obsessive-compulsive disorder (OCD), anorexia nervosa, and bipolar type schizoaffective disorder. The VA was not subject to guardianship. The VA’s Crisis Plan stated that the VA was to abstain from all non-prescribed substances, including THC, synthetic drugs, and alcohol. The VA was to take all prescribed medications and attend all mental health appointments as scheduled. The VA’s Care Plan stated that the staff persons were responsible for administering medications to the VA. The VA’s Individual Abuse Prevention Plan stated that the VA sometimes gave money to others because it was difficult for him/her to say no to requests for money. Allegation one: The SP took the VA to a smoke shop, where s/he purchased THC gummies. The VA then overdosed on nearly 3,000 mg of THC and was admitted to an emergency room for stabilization. The staff persons documented the following information in the Progress Notes: · August 10, 2025, 2 – 10 p.m.: [The VA] was in [his/her] room when staff arrived. [S/he] spent some time socializing with staff in the living room. [S/he] asked staff to take [him/her] to the Superior Smoke Shop and the gym. Staff took [him/her] to the gym and then to the smoke shop. [S/he] took [his/her] bedtime medications around 9 p.m. and then went to [his/her] room, where [s/he] remained until the end of the shift. · August 10 – 11, 2025, 10 p.m. – 7 a.m.: [The VA] was in [his/her] room when shift started then came up to watch TV, while in living room [s/he] was having a mild episode repeating words and asking what’s going on [s/he] went to sleep around 1 [a.m.]. · August 11, 2025, 7 a.m. – 3 p.m.: Upon arrival, [the VA] was in [his/her] bedroom. [S/he] appeared to be sleeping. At 9 a.m. I knocked on [the VA’s] door to wake [him/her]. [S/he] came upstairs and took [his/her] morning meds and we left for [the VA’s] appointment. I noticed [the VA] was a little out of it, but thought [s/he] might just be tired. [S/he] did not speak the whole way to the doctor. [S/he] barely kept [his/her] eyes open and was drooling a lot. We went to the Hermantown clinic where [the VA] got the two staples in [his/her] head removed. [The VA] is to keep [his/her] wound clean. We got back into my car and headed home. On the way home, [the VA] again, was very out of it. [S/he] was not [him/herself]. When we got home, [the VA] went down into [his/her] bedroom. I went downstairs and knocked on [his/her] door. I asked [him/her] if [s/he] was ok. [S/he] said yes. I advised [him/her] I was worried about [him/her] because [s/he] didn’t seem like [him/herself]. [S/he] said [s/he] was fine. Then I asked [him/her] why [s/he] went to the smoke shop yesterday. [S/he] advised [s/he] got some things for an old housemate. I advised [him/her] that [s/he] no longer lives here. [S/he] then self-admitted that [s/he] took two marijuana gummies. I asked [him/her] when [s/he] took those, [s/he] advised around 2 a.m. I asked [him/her] if [s/he] was hearing any voices and [s/he] said yes. [S/he] laid down on [his/her] bed and said [s/he] was very high and just wanted to sleep it off. I asked [the VA] if s/he had any more illegal items in [his/her] room, [s/he] said no. I advised I would be right here if [s/he] needs me or if [his/her] symptoms worsen - 10:50 a.m. 11:30 a.m. [The VA] came upstairs and I asked [him/her] if [s/he] wanted to help me with the grocery list. [S/he] said “no I feel funny” and started to go back downstairs. I asked [him/her] if [s/he] wanted anything (PRN) and [s/he] said no. 12:15 p.m. [The VA] asked me to take [him/her] to the emergency room. [S/he] says [s/he] feels funny and [his/her] throat is tight making it hard to breathe. [S/he] also advised me that the gummies [s/he] took were 1,000 mg each (equaling 2,000 mg of marijuana currently in [his/her] system). · August 11, 2025, 3 – 11 p.m.: [The VA] was in hospital when shift started, got picked up around 5 [p.m.] and went home, [the VA] was still complaining about [his/her] throat and still don’t feel good, [s/he] drank some water and ate some fruit, we picked up [his/her] meds around 6 [p.m.] and took it. Came back home then [s/he] ate dinner still feeling the same but a [little] bit better, 7 [p.m.] whole house went to the store, took [his/her] 8 p.m. [medications] now pacing back and forth listening to music for the rest of the shift. The facility’s Internal Review stated that the VA told the staff persons that on August 10, 2025, s/he took 2,000 mg of marijuana gummies at 8:30 p.m. and another 1,000 mg on August 11, 2025, at approximately 2 a.m. The VA provided the following information: · On one occasion, the VA asked the SP to take him/her to a smoke shop to purchase gummies. The staff persons were not supposed to take the VA to a smoke shop because of his/her commitment status. The SP was aware of the VA’s commitment and agreed to take the VA to the smoke shop but was initially hesitant about the VA purchasing gummies. The SP then looked up gummies on the internet and told the VA that s/he wanted to try them so the SP took the VA to a smoke shop in Wisconsin and went into the smoke shop with the VA. At approximately 7:50 p.m., the VA ate one of the gummies from the bottle while in the car driving back to the facility. At approximately 8:30 p.m., after they arrived back at the facility, the VA ate a second gummy and at 2 a.m., s/he ate a third gummy. The VA believed s/he paid $29.99 for the bottle of ten gummies and $6.99 for each of the two-packs. The next morning, the VA began to feel unwell and his/her throat felt “tight” so s/he asked P1 to take him/her to the hospital, where s/he was told that s/he overdosed on THC. The VA remained in the hospital for six or seven hours and it took four or five days for the VA to feel “normal.” · The following week, when the SP next worked at the facility, s/he told the VA not to tell anyone that the SP knew that the VA purchased gummies. The SP drove the VA to another location and had the VA throw the remainder of the gummies into the woods. The VA did not eat any more gummies after going to the hospital. · The SP typically took the VA to the gym and then left to run errands even when the VA first moved into the facility and had no unsupervised time in the community. At times, the VA had hallucinations at the gym and was unable to contact the SP to ask him/her to drive the VA back to the facility. The T provided the following information: · The VA was on a commitment and one of his/her restrictions was that s/he was not to go to any smoke shop or use any mind-altering substance, such as THC. The VA also had to take his/her medications and attend his/her therapy appointments. All of the staff persons were trained on the VA’s commitment restrictions. Although it was legal, THC “nullified” the VA’s medications and made his/her hallucinations “a lot more intense.” Recently, the VA told the T that the SP drove the VA to the smoke shop, where s/he purchased THC gummies. The VA ate 3,000 mg of the THC and the SP ate one of the VA’s gummies while s/he was with the VA. · The SP took the VA to the gym to work out and left the VA there for four hours while s/he went shopping. The SP was paid to supervise the VA, but did not do so when s/he left the VA at the gym. The VA sometimes had hallucinations at the gym but was unable to contact the SP to pick him/her up. The CM provided the following information: · On May 16, 2025, the VA was placed on a civil commitment. The VA had 12 hospitalizations during the previous year and the VA’s interdisciplinary team’s (IDT’s) goal was to prevent further hospitalizations. In the past, using THC products caused “negative outcomes” for the VA, such as increasing his/her schizophrenia and hospitalizations. The VA had four hours of unsupervised time in the community. The VA told the CM that s/he did not want to “get [the SP] in trouble” and the CM believed the VA might minimize the SP’s actions. · On May 28, 2025, the CM met with P1 and P2 to discuss the need to follow the VA’s Crisis Plan. The VA typically did not have a substance use disorder as much as the “occasional binging” that occurred on August 10, 2025. The CM believed that all of the staff persons were trained on the VA’s Crisis Plan.
P1 – P3 provided the following information: · P1 stated that on the morning of August 11, 2025, the VA was “very out of it,” was in and out of consciousness, was drooling, staring at the wall, and saying that the voices in his/her head were saying “not nice things.” P1 took the VA to the hospital and remained there with the VA for several hours because the VA had “so much marijuana in [his/her] system.” The VA told P1 that the SP took the VA to a smoke shop and waited in his/her car while the VA purchased 3,000 mg of THC gummies, which s/he ate over the next few hours. The VA did not give any wrappers or “proof” to P1 as to the type of gummies s/he ingested. P1 telephoned P2 and told him/her about the incident. Approximately one month after the VA’s hospitalization, the VA told P1 that the SP entered the smoke shop with the VA and purchased gummies and ate them with the VA. · P2 stated that although P1 told him/her about the incident, s/he did not report the incident or complete an internal review about the incident. P2 did not know why it was not done. After the incident, the VA’s IDT met with the VA to create a “kind of contract” about taking his/her medications, not using drugs like THC, and asking for the assistance of the staff persons when s/he experienced anxiety. · P1 stated that when the VA hallucinated, s/he frequently heard voices that told the VA to hurt him/herself and that if s/he did not hurt him/herself someone else in the world would die. P3 stated that the VA was “not supposed” to take gummies or drugs that were not prescribed for him/her. When the clients’ plans were changed, the staff persons had to read about the changes and sign a paper saying that they read the new plans. · P1 stated that the VA did not smoke cigarettes and did not need to go to a smoke shop. The staff persons were trained on the facility’s policies and on the VA’s care plans. P2 stated that the VA had four hours of unsupervised time in the community and had his/her own car, so s/he could have driven him/herself to the smoke shop. After the incident, the SP told P1 that s/he took the VA to the smoke shop because the VA asked him/her to do so. The SP provided the following information: · On August 10, 2025, the VA asked the SP to drive him/her to the smoke shop so that s/he could purchase a vape for his/her friend. The SP drove the VA to the gym, where they both worked out, and then to the smoke shop. The SP was unaware that the VA purchased anything other than a vape until two days later when a supervisor told the SP that the VA purchased “illegal stuff.” The SP did not know anything about THC gummies and did not recall if s/he entered the smoke shop with the VA. If the SP entered the smoke shop on that occasion s/he did not pay attention to what the VA purchased. The next time the SP worked with the VA, s/he asked why the VA lied to the SP about what s/he wanted to purchase and the VA apologized to the SP. The SP never told the VA to throw the rest of the gummies into the woods. · The SP did not receive training that the VA was not allowed to go to smoke shops or that the staff persons should watch what the clients purchased in a smoke shop. The SP might have signed off on various trainings, but might not have understood what the document said since English was not his/her first language. · The SP believed the facility wanted the VA to move out, so the VA was “blaming” the SP for the incident. The VA frequently “manipulated” others to get what s/he wanted. In addition, the SP had interpersonal conflicts with P1. The emergency room After Visit Summary stated that the VA “used a lot of marijuana today” which made him/her sleepy. Poison control recommended that the VA be observed for four hours, during which the VA’s condition improved. The physician did not believe the tightness in the VA’s throat was “anything emergent.” The VA was diagnosed with marijuana intoxication. Facility documentation showed that the SP, P1, P2, and P3 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Relevant Rules and Statutes: Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a), state that the license holder is to provide services in response to the individual’s identified needs, interests, preferences, and desired outcomes as identified in the individual’s plans. Conclusion for allegation one: A. Maltreatment: On August 10, 2025, the SP drove the VA to a smoke shop, where the VA purchased THC gummies, even though the VA was on a commitment and one of his/her restrictions was that s/he was not to go to any smoke shop or use any mind-altering substance, such as THC. This was a violation of Minnesota Statutes, section 245D.07, subdivision 1, paragraph (a). That night, the VA ate three 1,000 mg gummies and the following morning s/he appeared to be “out of it,” experienced hallucinations, and complained of tightness in his/her throat. The VA was taken to the hospital, where s/he was diagnosed with marijuana intoxication. Given that the SP taking the VA to a smoke shop where s/he accessed 1,000 mg THC gummies placed the VA at a significant risk of harm, there was a preponderance of the evidence that there was a failure to supply the VA with care or services which was reasonable and necessary to maintain the VA’s physical or mental health and safety. It was determined that 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). 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. 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, or abuse resulting in serious injury. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the VA did not sustain any injury that required the care of a physician. Allegation two: It was reported that the SP took two of the gummies from the VA’s pack of gummies. The VA stated that while at the smoke shop, she purchased a bottle of gummies that held ten 1,000 mg gummies and two packages that each had two 1,000 mg gummies. The SP asked for two of the gummies, which the VA gave to the SP from the bottle. The SP did not eat the gummies while s/he was with the VA. The SP did not pay the VA for the two gummies. P1 stated that the facility had a “zero tolerance” policy on the staff persons using drugs and alcohol. The staff persons were trained on the facility’s policies and on the VA’s care plans. P2 stated that s/he did not talk to the SP about whether s/he took any of the VA’s gummies. P3 stated that the staff persons were trained not to use drugs or alcohol when working at the facility. The SP stated that s/he did not ask the VA for any of his/her gummies and the VA did not give any gummies to the SP. Neither the clients nor the staff persons were allowed to use alcohol or marijuana in the facility. The SP never used marijuana or THC at any time. Conclusion for allegation two: The VA stated that the SP asked for two of the gummies s/he purchased at the smoke shop, so the VA gave a gummy to the SP. The SP stated that s/he did not ask for or receive a gummy from the VA and that s/he never used marijuana or THC. Although the VA stated that the SP asked him/her to throw away the rest of the gummies the VA purchased, no additional information was provided about how many gummies the VA purchased, what happened to the remainder of the gummies the VA stated that s/he purchased, or whether the SP took or ate any of the VA’s gummies. Taking a THC gummy from a client was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. However, given the inconsistent information provided by the VA and the SP and that no additional information was provided about whether the SP took a gummy that the VA purchased, and that the VA was not subject to guardianship, there was not a preponderance of the evidence as to whether the SP willfully used property belonging to the VA. It was not determined whether financial exploitation occurred (in the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Allegation three: During the course of the investigation, it was reported that the SP called the VA “heavy” and told him/her to spend more time at the gym. The VA stated that when s/he first moved into the facility, s/he was “really fit” and frequently worked out at the gym for four hours straight, but the VA no longer worked out as much and weighed more. The SP told the VA that s/he wanted to “look out for” the VA and told the VA that s/he was “bigger,” and members of the opposite sex would not like him/her now that s/he was bigger. The VA stated that it made him/her feel “really bad” when the SP made the comments, especially since s/he had an eating disorder. The VA frequently purged his/her food because s/he believed the SP’s comments were true. The VA never talked to the SP about his/her purging. The VA told the T about the SP’s comments and recently told P1 about the comments. The T stated that the VA had a “severe” eating disorder. In the past, the VA told the T that the SP made comments about the VA’s body and told the VA that s/he was getting “chubby,” which caused the VA to refuse his/her medications and then need hospitalization. The SP also took the VA to the gym to work out and left the VA there for four hours, which was “high above” the 90-minute exercise time recommended by the T and the VA’s dietician. The SP told the VA that s/he needed to go to the gym even when the VA told the SP that s/he did not want to go to the gym. P1 stated that on at least two occasions in the past, the VA told P1 that the SP told the VA that s/he was overweight and encouraged the VA to work out at the gym. The SP also asked the VA why s/he wanted to take all of the medications s/he was prescribed. P1 told P2 and the T about the SP’s comments. P1 never heard the SP make the comments. The SP worked every other weekend and P1 felt that the VA had more behaviors on the days after the SP’s work shifts. The SP stated that s/he never told the VA that s/he looked heavy or needed to lose weight and s/he would never say that to a client. Relevant Rules and Statutes: Minnesota Statutes, section245D.04, subdivision 3, paragraph (b), state that a person’s protection related rights include the right to be treated with courtesy and respect. Conclusion for allegation three: Consistent information was provided that the VA had an eating disorder. The VA stated that the SP told the VA that s/he was “bigger,” and members of the opposite sex would not like him/her now that s/he was bigger. The VA stated that it made him/her feel “really bad” when the SP made the comments. The VA provided consistent information that the SP made comments about his/her weight which was a violation of Minnesota Statutes, section245D.04, subdivision 3, paragraph (b). Although the VA provided consistent information about the SP’s comments, given that the SP stated that s/he never told the VA that s/he was heavy or that s/he needed to lose weight and that none of the other staff persons heard the SP make comments about the VA’s weight, there was not a preponderance of the evidence whether SP’s actions were repeated or were malicious oral language that would be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and could reasonably be expected to produce emotional distress to the VA. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were not adequate and were followed by the staff persons. After the incident, the staff persons were told that they could not take the VA to the smoke shop. 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. The facility was not issued a Correction Order for the violations outlined in this report because they took corrective action.
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