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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: 1072300-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jamie Randall jamie.randall@state.mn.us 651-431-4121 Suspected Maltreatment Reported: It was reported that a staff person (SP) had boundary issues with three vulnerable adults (VA1, VA2, and VA3) that included spending extended periods of time in the VAs’ bedrooms with the doors closed and using methamphetamine and vape pens that contained tetrahydrocannabinol (THC) with the VAs, and that the SP was in a relationship with VA1. Date of Incident(s): Prior to January 1, 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 January 22, 2026; from documentation at the facility; and through seven interviews conducted with VA1, VA2, a supervisory staff person (P1), and four staff persons (P2-P5). VA3 met this investigator but declined to be interviewed. Attempts were made via telephone and certified and non-certified mail to contact the SP, who was a supervisory staff person, to request an interview but the SP did not respond. VA1 enjoyed watching movies, doing yoga, bowling, and fishing. VA1’s diagnosis included schizoaffective disorder (bipolar type), mild neurocognitive disorder, hearing loss, and a history of substance use. VA1 had a goal “to manage [his/her] mental health symptoms and stabilize [his/her] mood” which included substance use and “possession of paraphernalia.” Substance use included “alcohol, THC, or any legal drug inappropriately or illegal drug substance by inhalation, injection, snorting, swallowing (marijuana, cocaine, amphetamines, barbiturates, hand sanitizer, cough and cold medicine).” VA1 was “not likely to seek; but may cooperate in a sexual abusive situation” and may not “accurately report harm/abuse.” Staff persons were to “observe for changes” in VA1’s behavior and talk with VA1 “to see why [s/he] appears upset.” VA1 had one hour of unsupervised time in the community time to walk to and from the facility to his/her job on VA1’s scheduled workdays. VA2 enjoyed fishing, bike rides, and lifting weights. VA2’s diagnoses included post-traumatic stress disorder (PTSD), anxiety disorder, opioid use disorder, cannabis use disorder, cocaine use disorder, and major depressive disorder. VA2’s plans included that VA2 had a history of making untrue statements. VA2 had a goal “to manage [his/her] mental health symptoms and stabilize [his/her] mood” which included substance use but did not apply to “prescribed medical marijuana.” Substance use included “alcohol, THC, or any legal drug inappropriately or illegal drug substance by inhalation, injection, snorting, swallowing (marijuana, cocaine, amphetamines, barbiturates, hand sanitizer, cough and cold medicine).” VA2 could be unsupervised in the community for 18 hours. VA2 was to let staff persons know where s/he was going to be and “sign in and out at all times.” VA2 was to have the phone numbers where s/he could reach staff persons or an on call supervisory staff person. VA2 could be “easily persuaded and manipulated by others.” When VA2 used substances, it lowered VA2’s “inhibitions” which had led to “increased verbal aggression, lowered social boundaries, and bringing unknown persons” to the facility. Staff persons were to “provide training on appropriate boundaries and how to identify harmful or abusive situations.” VA3 enjoyed bowling, movies, frisbee golf, basketball, and watching sports on TV. VA3’s diagnoses included schizophrenia, depression, and anxiety disorder. VA3 had a goal “to manage mental health symptoms and decrease instances of interfering behaviors” which included substance use and “possession of paraphernalia.” Substance use included “alcohol, THC, or any legal drug inappropriately or illegal drug substance by inhalation, injection, snorting, swallowing (marijuana, cocaine, amphetamines, barbiturates, hand sanitizer, cough and cold medicine).” VA3’s plans included that s/he could be unsupervised in the community for 16 hours. VA3 was to notify staff when s/he left the facility and when s/he would return. If VA3 left the facility with anyone other than two listed family members, staff persons were to follow VA3 “if able” and to contact an on call supervisory staff person. VA3 “may not report abuse as [s/he] believes that it would be something [s/he] would be uncomfortable talking to people that [s/he] is not close with.” Staff persons would “attempt to develop trusting relationships with [VA3]” to help VA3 “feel comfortable” with staff persons. The facility was two levels with a basement. VA2’s and VA3’s bedrooms were on a main level and VA1’s bedroom was in the basement. On the main level, there was a living room to the right of a front entry with a window that faced a street. There was a door to the left of the front entry that led to a garage. There was a living room in the basement that was next to VA3’s bedroom. There was a locked staff office in the basement. The facilities Drugs and Alcohol policy “prohibits unlawful manufacture, distribution, dispensation, possession or use of alcohol, illegal narcotics, drugs or controlled substances while on company business, providing services, using company vehicles or on company property.” Staff persons were “prohibited from being under the influence of a controlled substance as identified under Minnesota Statute, chapter 152 or illegal drugs in any manner that impairs or could impair an employee’s ability to provide care or services to persons receiving services.” The facilities Safe Transportation Policy said that staff persons would “ensure safe transportation, handling and transfers of the person and any equipment used by the person when assisting a person who is being transported” and that staff persons were “responsible for the supervision and safety of persons while being transported.” P1 provided the following information to this investigator and for the facility’s internal review: · The internal review included that on November 25, 2025, the SP found tinfoil in the garage that the SP suspected was from drug use as the tinfoil had “remnants of substance left.” P1 told the SP to destroy the tinfoil “wearing protective gear” and to record on the facility’s Substance Use Destruction Record. The Substance Use Destruction Record did not have this recorded. · On December 6, 2025, a supervisory staff person, who was on call for the facility, went to the facility as there were concerns that the SP was working while under the influence. P4 said that the SP sat on a couch in the basement that was outside of VA1’s bedroom and “something was off.” The supervisory staff person was at the facility for an hour, and the SP did not show any signs of being under the influence. · The internal review included that on December 16, 2025, P1 had a conversation with the SP that regarded boundaries with the VAs supported at the facility. The SP would spend time in the VAs’ bedrooms with the doors closed and had stayed at the facility after his/her shift ended to “hang out” with the VAs. · On December 17, 2025, there was a staff meeting. The SP brought up that s/he was “not doing anything inappropriately” with any of the VAs. The SP said that s/he did not “do drugs” and that s/he had a family member that died from drug use. The SP just “brought it up” which P1 thought was interesting as no one present “asked [him/her] anything.” · On December 27, 2025, P1 had a conversation with the SP as the SP had stayed clocked in multiple times past his/her scheduled end time. · On January 1, 2026, P3 informed P1 that when s/he arrived for his/her shift at 8:40 p.m., that day prior that s/he could not find the SP. P3 knocked on the VAs’ bedroom doors and found the SP in VA2’s room. The SP was sitting in VA2’s bed with VA2 and VA3. P3 asked the SP for a “rundown” of what had happened during the shift. P3 thought that the SP may have been under the influence as the SP talked “so fast” that P3 could not understand what the SP said to him/her. The SP clocked out at 9 p.m. and stayed at the facility until 11:20 p.m. The SP, VA2, and VA3 went into the garage to smoke cigarettes. P3 though that the behavior was odd and followed the VAs and the SP into the garage. P3 saw the SP put a “baggie” of something into VA3’s hand but could not tell what was inside. The SP and VA3 got into the SP’s vehicle and drove away from the facility. VA3 returned to the facility 15 to 20 minutes later in a cab for which VA2 had paid the cab fare. · P1 contacted two administrative staff persons and informed them of the events from the overnight shift. P1 and one of the administrative staff persons talked with the SP and placed the SP on leave. The SP was told that s/he should not contact staff persons or the individuals supported at the facility and was not to come to the facility while on leave. · After the SP was put on leave, the SP left the facility and sat in his/her vehicle. P4 saw VA2 leave the facility and sit in the SP’s vehicle with the SP for twenty minutes. When VA2 came back inside the facility, s/he told P4 that the SP told him/her that s/he was “having a really bad day” and that VA1 and the SP “broke up” the day before. · Around 9:40 p.m., VA2 left the facility and told P3 that s/he was going on a “date.” P3 watched VA2 leave and VA2 walked down the street, approached a vehicle, and opened the passenger door. When the door opened, P3 saw the SP in the driver’s seat. P3 told P1 that he saw VA2 get into a vehicle with the SP. P1 called the SP, but the SP did not pick up the phone. P1 texted the SP, “You need to drop [VA2] back off at the [facility],” and “[The SP] this is a violation of your admin leave,” which showed a “read” notification, but the SP did not respond. VA2 arrived back at the facility at 9:55 p.m. and had a plastic bag with him/her. P3 could not tell what was in the plastic bag. · On January 3, 2026, VA2 told P3 that s/he was going to the hospital for “swelling of [his/her] feet.” VA2 also told P3 that s/he was going to help a friend set up a surround sound system at their home. VA2 set up a ride with a ridesharing service and left the facility. P3 was unsure if VA2 went to the hospital or to the friend’s home to help set up the surround sound system. P3 told P1 that the SP got a new surround sound system and though that VA2 may have been talking about helping the SP. VA2 had a history of not being “completely honest.” · On January 4, 2026, VA2 came back to the facility and went straight to his/her room. A day or two after January 4, 2026, VA2 told P1 that s/he went to the hospital on January 3, 2026, and had a new medication. P1 asked a facility nurse if VA2 had a new medication and s/he had no information. There was no “general proof” that VA2 was at any of the local hospitals. P4 provided the following information: · On December 6, 2025, P4 worked a shift with the SP. The SP spent most of the shift on the basement level sitting on a couch in the basement living room. Two times during the morning, VA2 told P4 that the SP and VA1 were “smoking meth.” VA2 told P4 that s/he thought the SP and VA1 were in a relationship as VA1 asked VA2 for “tips” on “how to do it.” At an unknown time in the morning, P4 went downstairs, and the SP was on the couch. P4 asked the SP about the SP “smoking meth” and if s/he was in a relationship with VA1. The SP told P4 that VA2 was a “liar” and “that’s not happening.” P4 told the SP that s/he was following up on what VA2 had told P4. The SP was on the couch and P4 went upstairs. · At some point after P4 talked with the SP, VA1 and VA2 whispered to each other on the main floor before VA1, VA2, VA3, and another client that lived in the facility went downstairs to talk with the SP. P4 was upstairs and could hear whispers but not what was being said between the VAs and the SP. VA2 came upstairs and asked P4 to take him/her to a local convenience store. On the drive to the convenience store, VA2 said that the SP admitted to the drug use and asked for help as s/he “didn’t know what to do.” · An unknown person told a supervisory staff person about the concerns with the SP and possibly being under the influence. While P4 made dinner, the supervisory staff person came to the facility to speak with the SP. After s/he spoke with the SP, the supervisory staff person told P4 that the SP seemed “fine.” The supervisory staff person thought it was “odd” that the SP only said, “Hi,” to him/her but did not have any concerns. The supervisory staff person stayed for an hour and left the facility. P4 thought that everything must have been fine but still had a “weird feeling” about the SP. The SP seemed “nervous” and “irritated” after the supervisory staff person talked with the SP. · P4 texted P2 throughout the shift as s/he was not sure “what to think” about what VA2 had told P4. VA2 had a history of not always being truthful and had made false accusations in the past. P2 asked P4 if any of the VAs seemed “high” and P4 though that VA1 may have been under the influence as VA1’s eyes were “red” and “glossy.” · On an unknown date the week following December 6, 2025, P4 was working a shift with the SP and another staff person. When P4 arrived for his/her shift, the SP was in VA1’s bedroom. VA1 was standing in the room while the SP was in VA1’s bed. VA1’s bedsheet covers were “messed around” and P4 could tell the SP was “comfy” as s/he was “partially” under the covers. The SP and VA1 told P4 that they were watching a movie. P4 though that VA1 might have been under the influence of a substance as VA1’s eyes were “glossy” and “bloodshot.” P4 went downstairs and checked on VA1 and the SP two or three times during the shift. The SP was on his/her phone and one of the times s/he went downstairs, P4 saw the SP asleep. The SP stayed in VA1’s bedroom for five or six hours, which P4 and the other staff person thought was odd. P4 thought it was “strange” for the SP, who was a supervisory staff person, to “clock in and then not do anything” beside spend time with VA1. · On an unknown date the week following December 6, 2025, when P3 arrived for a shift, P4 and P3 asked VA1 if something was “going on” and that VA1 could tell P3 and P4 as they were worried about VA1. VA1 said, “No, no, no” to P3 and P4’s questions. VA2, who was in the same room where the conversation took place, told VA1, “You know what they’re talking about.” VA1 did not provide any details to P3 or P4. · On an unknown date after December 6, 2025, the SP showed multiple staff persons tinfoil that s/he found in a bag in the garage that s/he claimed had been used to “smoke meth.” P4 thought it was “convenient” for the SP to find the tinfoil after the accusation that the SP smoked methamphetamine with VA1. On an unknown date, P4 found a package of tinfoil with the SP’s personal items in a closet that was in the staff office. P4 thought it was strange for tinfoil to be kept there and was unsure if the tinfoil was the facility’s or the SPs. · VA2 made jokes about VA1 and the SP being in a relationship. On one occasion when VA2 made a joke, VA3 laughed at the joke and “acknowledged” that VA1 and the SP were in a relationship. · When the SP started to work at the facility, VA1 started to mainly talk with only the SP. Since the SP stopped working at the facility, VA1 had spent more time upstairs at the facility and engaged more with staff persons. P3 provided the following information to this investigator and for the facility’s internal review: · On an unknown date in the week prior to December 25, 2025, the SP told P3 that s/he planned to go home and see his/her child after s/he dropped off VA3 at a bar. The SP left the facility at 9 p.m. with VA3. At 3 a.m., the SP called P3 and told him/her that s/he would be coming to the facility. P3 was confused as to why the SP needed to come to the facility at 3 a.m. When the SP arrived at the facility, P3 noticed the SP’s eyes “looked crazy” like s/he was under the influence of something. The SP’s hands were covered in what looked like “black soot.” The SP knelt on the floor next to a couch in the main floor living room. The SP told P3 that s/he did not go home after s/he dropped VA3 off at the bar but did not say what s/he did prior to coming to the facility. The SP talked for three hours about various subjects and talked to him/herself before s/he left the facility. · On Dec 31, 2025, P3 arrived at the facility at 8:40 p.m. P3 went to clock in but the office door was locked, and s/he needed a key from the SP. P3 did not see the SP anywhere and knocked on VA1’s door. VA1 did not know where the SP was so P3 went upstairs. P3 heard music in VA2’s room and knocked on the door. VA2 opened the door and P3 saw the SP sitting on VA2’s bed with VA3. Next to the SP was a torch and two THC vape pens. The SP used the THC vape pen and offered it to VA2 and VA3 (note: P3 did not tell this investigator whether s/he saw VA2 and/or VA3 use the THC vape pen but did provide in the facility’s internal review that the SP used the THC vape pen with VA2 and VA3). The SP got up from VA2’s bed and went to the living room where the SP used his/her phone to clock P3 in for his/her shift and the SP clocked out for his/her shift at 9 p.m. The SP was “visibly sweating” and his/her pupils were dilated. The SP stayed in the living room and talked to P3 for an hour. The SP used the THC vape pen multiple times and talked so fast that P3 could not make out what the SP said. The SP offered for P3 to use the THC vape pen multiple times during the hour and P3 declined each time. The SP went back into VA2’s bedroom. · In the internal review, P3 said that at 11:20 p.m., the SP prepared to leave the facility and was in the living room with VA2 and VA3. The SP put something in VA3’s hand but could not tell what it was as the SP and VA3 were behind the couch. The SP and the VAs went into the garage to smoke cigarettes and P3 followed. The SP and VA3 left in the SP’s vehicle. VA3 came back to the facility about 20 minutes later in a cab for which VA2 paid the cab fare. · On Jan 1, 2026, around 10 p.m., P3 sat on a couch that was in the living room and was looking out the living room window. VA2 paced back and forth in the living room and told P3 that s/he was “going on a date” and would be gone for two hours. VA2 said s/he did not look good and was worried about his/her shoes. P3 provided encouragement to VA2. P3 saw a vehicle that looked similar the SP’s parked down the street. VA2 said, “Nosy mother fuckers” and closed the blinds to the window. VA2 left the facility and P3 opened the blinds. VA2 walked toward the vehicle and when VA2 opened the passenger door, a light turned on in the vehicle and P3 saw that the driver was the SP. P3 called P1 who then called the SP. VA2 returned to the facility around 15 minutes later with a plastic bag. When VA2 got into the facility, s/he said, “I wasn’t with [the SP].” P3 did not say anything prior to VA2’s comment. VA2 complained that s/he got dropped off and that s/he lived at the facility. P3 did not know what was in the plastic bag. · On Jan 3, 2026, P4 and P5 were working when P3 came in for his/her shift. VA2 left at 6 p.m. as s/he was going to help a friend set up a surround sound system. VA2 used a ride sharing service and the ride was to the same city that the SP lived. P3 remembered the SP talked about getting a new surround sound system for the holidays and thought that VA2 went to the SP’s house. · On an unknown date, VA2 told P3 that the SP and VA1 were in a sexual relationship but P3 was not sure if what VA2 said was true as VA2 had not always been truthful in the past. After the SP was not working at the facility, P2 and P4 talked about the SP being in a possible sexual relationship with VA1. P4 told P3 that the SP would stay past his/her scheduled shifts in VA1’s bedroom. P3 was not sure if the SP and VA1 were in a relationship but the SP would spend time in VA1’s room with the door closed. The SP would sit on VA1’s bed with him/her which P3 thought was inappropriate behavior. VA1 had a different cultural background compared the that of the SP and P3 felt that the SP was “fetishizing” VA1’s culture. When P3 first started to work at the facility, the SP would make foods from VA1’ culture, which P3 thought was inclusive but VA1’s culture became a topic that the SP would talk about often. · P3 thought that the SP was “unprofessional” and “off putting.” The SP would “karma dump” on other staff persons and would share too much about his/her personal life to P3. The SP carried a THC vape pen with him/her and offered P3 to use the vape pen multiple times while working at the facility to which P3 would decline. The SP used the vape pen a “handful” of times while at the facility while P3 was present. P2 provided the following information: · On December 6, 2026, P4 and P2 texted during a shift where P4 worked with the SP. P4 texted the concerns that s/he told this investigator to P2. P2 text messages to P4 included that the SP should “spend more time with [VA1] in open spaces” and that s/he did not understand why the SP was “so close to [VA1].” P2 mentioned that VA1 “sits in [his/her] room and sneaks to smoke meth.” P2 said that “this is the [third or fourth] time [the SP has] either been in [the VA’s] room for hours or on the couch outside [his/her] door for hours.” P4 mentioned that VA2 and VA3 were “joking” about the SP and VA1. P2 responded that the SP was “giving them a reason to joke and make remarks.” P2 thought that it was weird for the SP to spend hours with VA1 and not pay attention to any of the other VAs. · About three weeks prior to January 22, 2026, P2 worked a shift that started at 9 p.m. Around 10 minutes into the shift, VA2 told P2 that the SP offered to give him/her a massage and asked if that was appropriate. P2 told VA2 that it was not appropriate and VA2 said that the SP would spend “hours” in his/her room and sometimes the whole shift the SP worked. On an unknown date prior to this conversation, VA2 told P2 that the SP asked VA2 if s/he could hug him/her and VA2 declined. · The SP spent long periods of time that included more than five or six hours in VA1’s and VA2’s bedrooms with the door closed on multiple occasions. P2 said that staff persons tried talking with the SP about the concerns with being in VAs’ rooms for hours and that VA2 and VA3 made jokes about the SP and VA1 but it “didn’t change anything.” · VA1, VA2, VA3, and another client receiving services at the facility all had issues with substance use that included methamphetamines. VA2 and VA3 made comments to multiple staff that the SP and VA1 would use meth together. P2 had not seen the SP use drugs or act like s/he was under the influence. VA2 provided the following information: · VA2 said that the SP and VA1 were “both adults” and chose to be in a relationship. The SP and VA1 would spend time in VA1’s bed and act like “best friends.” At first, VA2 thought that the SP and VA1 were having “one on ones” but it was “different.” The SP and VA1 “held hands” and “kissed.” When asked if anyone else saw the SP and VA1 kiss, VA2 said, “How could they not?” On an unknown date VA1 asked VA2 for tips on “how to do it.” The SP and VA1 had “sex” but never at the facility. · On unknown dates “toward the end” of when the SP worked at the facility, the SP started to spend time in VA2’s bedroom. The SP would sit on VA2’s bed and would talk about “problems” that VA1 and the SP had. VA2 found this to be “weird” and did not like that the SP spent so much time in his/her bedroom. VA2 felt like s/he was a “counselor” for the SP and told the SP to leave his/her room and not sit on his/her bed. · On an unknown date “just before” the SP’s last shift, VA2 went to the SP’s house to help a family member of the SP set up a surround sound system. VA2 told an unknown staff person that s/he was going on a “date”, but it was just to help the SP’s family member set up the surround sound system. · On an unknown date, the SP was in VA2’s bedroom sitting on VA2’s bed when P3 arrived for his/her shift. P3 was at the doorway of VA2’s bedroom and VA2 asked P3 to come into his/her bedroom as s/he wanted the SP to leave. After about an hour, the SP got up and left VA2’s bedroom. Later that night, the SP dropped VA3 off at a local bar where one of VA3’s friends lived. · The following day, the SP was put on leave. The SP left the facility at 12:30 or 1 p.m. and sat in his/her vehicle. VA2 left the facility and sat in the SP’s vehicle with the SP. The SP told VA2 the reasons why s/he was leaving was because of things that VA2 said and that s/he was in trouble for dropping VA3 off at a bar. VA2 told the SP that the reason s/he was leaving was because of the SP’s actions and drug use. VA2 said that on the day that the SP drove VA3, that the SP was not supposed to still be at the facility as his/her shift had ended. · The SP was “nice” but took “advantage of the situation.” The SP, as a supervisory staff person, should have known better and kept “boundaries.” The SP “smoked meth” every day when s/he worked at the facility. The SP was scheduled to leave at 4 p.m. most days but would stay until 10 or 11 p.m. VA1 provided the following information: · VA1 said that s/he and the SP were in a relationship and that VA1 and the SP “kissed.” When asked if VA1 and the SP had any sexual contact, VA1 said, “I don’t know” and “I’m not sure.” When asked if the SP touched him/her anywhere else, VA said, “No, nothing” and that s/he and the SP just kissed. VA1 was not sure if s/he and the SP were still in a relationship. · When asked if the SP had drugs at the facility, VA1 said, “I don’t know. I’m not sure.” VA1 said, “I don’t know” when asked if s/he had seen or heard anything regarding the SP and drug use when the SP worked at the facility. VA1 said that unknown staff persons would check his/her room and ask him/her, “what [s/he] had?” VA1 did not remember staff persons taking any items from his/her room and that the staff persons would leave when they saw “nothing.” P5 provided the following information: · On December 25, 2025, P5 worked a shift with the SP. The SP did not act like his/her normal self, had red eyes, and was “really quiet.” The SP went outside with VA1 for about an hour as VA1 smoked cigarettes but otherwise spent the shift in the basement. The SP normally talked with staff persons so P5 found the SP’s behavior, in addition to the SP’s red eyes, as “weird.” The SP was scheduled to be off at 4 or 4:30 p.m. and P2 arrived to help P5. The SP stayed past his/her scheduled time and spent the next two hours in VA2’s room. P5 asked P2 if s/he felt that the SP acted weird and P2 agreed. · The SP would “always” stay later than his/her scheduled shifts. The SP would spend time in VA1’s and VA2’s bedroom with the doors closed. · P5 felt that VA1 was reliable when recalling events but noted that VA1 was quiet and would not say much when staff persons asked him/her questions. VA2 “sometimes” was reliable, and “parts” of his/her stories were true but liked to “bend the truth.” Facility records showed that P1-P5 and the SP were trained on the VAs plans, the facility’s Drugs and Alcohol Policy, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Regarding VA1: VA2 told multiple staff persons that the SP and VA1 were in a relationship. VA1 told this investigator that s/he and the SP were in a relationship and “kissed” but did not say if there was sexual contact between VA1 and the SP. Multiple staff persons said that the SP had boundary concerns with VA1 which included spending hours in VA1’s bedroom and sitting on VA1’s bed with VA1. The SP would stay past his/her scheduled shifts and spend that time in VA1’s and VA2’s bedrooms. VA2 said that the SP and VA1 would “smoke meth” in VA1’s bedroom or in the basement living room outside of VA1’s bedroom. While VA2 had a history of not always being truthful, the SP was witnessed to have displayed signs of being under the influence while at the facility on multiple occasions by multiple staff persons and was witnessed by multiple staff persons spending hours with VA1 and in VA1’s bedroom, which gave credibility to what VA2 said. Given that VA2 told multiple staff persons that the SP and VA1 were in a relationship, that VA1 told this investigator the SP and VA1 were in a relationship and kissed, and that the SP’s interactions with VA1 likely hindered VA1’s ability to have a consistent understanding of the parameters of a therapeutic relationships, there was a preponderance of the evidence that there was a failure to supply the VA with care and services that were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety and that the SP failed to maintain professional boundaries which was detrimental to VA1’s mental health. 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). Regarding VA2: VA2 had concerns that the SP spent hours in his/her room and would sit on his/her bed. VA2 told P2 that the SP offered to give him/her a massage and asked VA2 if s/he could give him/her a hug, which VA2 declined. VA2 said that the SP and VA1 would “smoke meth” but the SP did not use with anyone else. VA2 went to the SP’s home to help a family member of the SP set up a surround sound system. VA2 told this investigator that this occurred prior to the SP’s last shift, which was on January 1, 2026, but P3 and documentation from the facility said that VA2 went to a friend’s house to help set up a surround sound system on January 3, 2026. There was information that the SP offered a THC vape to VA2 but no information that VA2 accepted and used the THC vape pen. Although VA2 had concerns that the SP did not maintain professional boundaries and engaged in behavior inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, there was not a preponderance of the evidence whether the SP’s interactions with VA2 rose to the level of neglect to represent a failure to supply VA2 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.) Regarding VA3: On December 31, 2025, P3 arrived for his/her shift at 8:40 p.m. and could not find the SP. P3 heard music in VA2’s room and knocked on the door. VA2 opened the door and P3 saw the SP sitting on VA2’s bed with VA3. Next to the SP was two THC vape pens and a torch. The SP used the THC vape pen and offered it to VA2 and VA3. The internal review said that the SP used the THC vape pen with VA2 and VA3 but P3 did not tell this investigator whether s/he saw VA2 and/or VA3 use the THC vape pen and there was no information that they did. The SP got up from VA2’s bed and went to the living room where the SP used his/her phone to clock P3 in for his/her shift and the SP clocked out for his/her shift at 9 p.m. The SP was “visibly sweating” and his/her pupils were dilated. The SP stayed in the living room and talked to P3 for an hour. The SP used the THC vape pen multiple times and talked so fast that P3 could not make out what the SP said. The SP offered for P3 to use the THC vape pen multiple times during the hour and P3 declined each time. The SP then went back into VA2’s bedroom. At 11:20 p.m., the SP prepared to leave and while the SP and VA2 were in the living room, the SP appeared to put something in VA3’s hand. The SP, VA2, and VA3, went into the garage to smoke cigarettes and P3 followed. The SP and VA3 left in the SP’s vehicle with the SP driving. VA3 came back to the facility about 20 minutes later in a cab for which VA2 paid the cab fare. Given that P3 saw the SP use a THC vape pen more than once about an hour or two prior to driving VA3 and that the SP displayed signs of being under the influence, there was a preponderance of the evidence that the SP drove VA3 while under the influence which posed a significant risk of harm to VA3 representing a failure to supply the VA with care and services that were reasonable and necessary to obtain or maintain the VA’s physical or mental health or 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. The SP was trained on VA1’s and VA3’s plans, the facility’s Drugs and Alcohol Policy, the facility’s Safe Transportation Policy, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1 and VA3. 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 was not “serious” maltreatment because VA1 and VA3 did not require care of a physician but was “recurring” maltreatment because the SP was responsible for two incidents of maltreatment, one with VA1 and one with VA3. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed. All staff persons were retrained on the Reporting of Maltreatment of Vulnerable Adults Act and “redirecting, safe handling, destruction policies, and reporting substance use in the program.” The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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