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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: 1122087-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071829-HCBS (Home and Community-Based Services) Investigator(s): Jamie Randall 651-431-4121 Suspected Maltreatment Reported: It was reported that $246.60 in cash and $20 worth of gift cards that belonged to a vulnerable adult (VA) were missing from a safe that was stored in a locked staff office. Date of Incident(s): Prior to February 2, 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 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 February 25, 2026; from documentation at the facility and bank statements; and through eight interviews conducted with three supervisory staff persons (P1-P3), four facility staff persons (P4-P7), and the VA’s guardian (G). This investigator met the VA but did not interview the VA. The VA’s team decided that for the VA’s mental health and wellbeing, the VA was not told that cash and gift cards were missing. The VA enjoyed playing “Magic the Gathering,” music, and “art” on YouTube. The VA’s diagnoses included epilepsy, general anxiety disorder, and depression. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to financial exploitation. The VA had a history of losing money, not keeping receipts, and was “unsure of getting or giving the correct change.” The facility provided cash management for the VA. The VA required assistance with personal spending money and staff were to assist the VA with obtaining all receipts for purchases of over $10. If a receipt was “not available” or if the VA “throws it away,” staff were to complete a “missing receipt form.” The VA was able to receive $30 in cash weekly. The facility’s Management of an Individual’s Monetary Resources Policy said that “money belonging to people served” was to be “kept secure and accountability ensured.” “Cash on hand per person should not exceed $50 or as otherwise indicated on the person’s financial transaction consent.” Any amount kept on hand that exceeded $50 required approval from a supervisory staff person. The facility was three stories with a basement. The VA’s bedroom was on the upper level. A staff office was also on the upper level and had a door with a code lock. All staff persons knew the access code to get into the staff office. The VA’s cash and gift cards were stored in a keyed safe in the staff office. The key to the safe was stored on a hook on the staff office wall. There was a green binder in the staff office where the ledgers for the VA’s money were kept. The facility’s internal review, the VA’s ledgers, and the VA’s bank statements provided the following information: · The VA had three ledgers for different categories of cash on hand. The three categories were “allowance,” “personal needs,” and “social outings.” The VA had a checking and savings account. There was a debit card for the checking account which the VA kept in their wallet. · Ledgers for the VA’s cash showed the following accounting discrepancies: o On October 9, 2025, there was a transaction where $40 was taken out of one of the VA’s cash ledgers for a t-shirt at a local store (note: the ledger does not say which category but “personal care” from September 2025 had the same amount of cash listed as the beginning balance). The amount deposited as “change” from the local store was $15.01 but the current balance added only $14.16. There was no receipt for this transaction and the Cash Acknowledgment Voucher filled out said $15.01 was deposited. o On November 10, 2025, there was a “social outings deposit” for $5 as indicated on the “social outings” ledger and the Cash Acknowledgment Voucher. The current balance amount added was $5.30. o On January 6, 2026, there was a “deposit allowance” listed for $20 as a deposit with an arrow pointing to the withdrawal section of the ledger. The amount balanced added $20 to the current balance. Bank statements showed that $10 was deposited into each of the VA’s checking and savings account on January 6, 2026. o On January 11, 2026, there was a $5 deposit into the VA’s “personal needs” and another $5 deposit into the VA’s “social outings.” These two transactions were not tracked on the “allowance” ledger. · The VA’s cash and the envelopes containing the cash for the three categories were found to be missing from the keyed safe on February 2, 2026, by P2 and P4. The VA had two $10 gift cards that were also missing from the safe. The VA’s last transaction recorded on the ledgers was on January 11, 2026. The balanced amount between the three cash categories was $246.60. P2 provided the following information: · On an unknown Monday near the end of January 2026, P2 and P4 went into the staff office to get the VA’s money ready to be deposited the following day. P2 opened the locked safe where the VA’s money was kept and found three empty envelopes that should have had the VA’s cash in them (note: P2 first told this investigator the envelopes were missing but then said that the envelopes were empty as s/he remembered opening them and seeing they were empty. This was the only mention of the envelopes as not missing as well as the cash). The VA was also missing two gift cards that were $10 each. Due to recent activity in the community, the VA had only attended appointments and had not gone to the bank “for the month.” The last time the VA’s money was counted was January 11, 2026, by P4. · The G would drop off $140 in cash for the VA every month. The VA had three envelopes for cash and three ledgers that pertained to each envelope. The $140 would be put in the envelope labeled “allowance” and then each week, $30 would be taken out of “allowance” with $5 going into the envelope labeled “social outings,” 5$ going into the envelope labeled “personal needs,” and $20 was deposited into the VA’s bank account. The VA had a checking and saving account and would choose how much of the $20 was deposited into each account. When the VA deposited money in the bank or made a purchase, staff persons would assist the VA with documenting transactions to make sure “it adds up.” The VA had a debit card that was kept in the VA’s wallet. · P2 said that s/he should have been counting the VA’s money weekly. The last time that P2 counted the VA’s money was when the G brought $140 in cash for the VA on January 3, 2026. P2 said that s/he had “too much trust” in staff persons when asked why counting was not completed weekly. · P2 denied taking the VA’s money. P1 provided the following information to this investigator and for the facility’s internal review: · On the evening of February 2, 2026, P1 missed a phone call from P2. P2 texted P1 that money was missing and that P1 needed to call P2. P2 called P1 and was told that the VA planned to go to the bank on February 3, 2026, and P2 was getting the VA’s cash ready that was to be deposited but the three envelopes that contained the VA’s cash were missing, and the cash was gone. P1 asked P2 when the last time was s/he saw the VA’s money and P2 said that due to recent activity in the community, the VA had not gone out in the community and mostly stayed at the facility. P2 said that due to the VA not going out, s/he had not gone into the money and that s/he only counted the VA’s money when there was a transaction. P1 was not sure but thought P2 said January 9, 2026, was the last time P2 saw the VA’s money. · On February 3, 2026, P2 told P1 that the VA was also missing two gift cards. P1 was not sure but thought that the total amount missing from the VA was $283 and “some change.” · Within the first “five days or so” of every month, the G would bring $140 in cash to the facility for the VA. The VA’s money was kept in a locked staff office where there was a keyed safe. The key for the safe was kept in the staff office. In the safe, the VA had three envelopes, one for “personal needs,” one for “outings,” and one for “allowance,” that the VA’s money would be divided into. The VA would have a choice to put either $5 or $10 into the VA’s savings account each week. Staff would document when the money was received and then any subsequent transactions on separate ledgers for each of the three envelopes. · Each month, the balance of the three ledgers would be transferred onto a document called a Cash Resource Record that P1 was to complete by the 10th of each month. P1 was not sure when the last Cash Resource Record for the VA was completed but thought October or November of 2025. P1 said that there was “no good excuse” for why s/he had not completed a Cash Resource Record as s/he was supposed to each month and should have asked P3 for help. · P1 denied taking the VA’s money. P4 provided the following information to this investigator and for the facility’s internal review: · On January 7, 2026, the G dropped off money for the VA and P2 entered the transaction on the “register.” On January 11, 2026, $5 for both “social outings” and “personal needs,” were moved from the “allowance” balance. The VA was going to put money in the VA’s bank account on January 11, 2026, but ended up not going to the bank. P2 did not say why the VA did not go to the bank on January 11, 2026, but did say that due to recent activity in the community, “individuals” did not want to go out because they were “scared.” · On an unknown date in late January or early February 2026, P4 and P2 were in the office to get the VA’s money together for a deposit the following day. The VA’s envelopes where the VA’s cash was kept were missing and the money was gone. P4 and P2 “freaked out” as something like that had not happened before. P2 was not sure how much money was missing from the VA and could not believe someone would take money from the VA. · The VA’s money was kept in a keyed safe in the locked staff office. The key was kept on a key ring inside the staff office. Both the staff office and the keyed safe were kept locked at all times. When cash was given to the VA, a receipt was signed by the VA and the staff person that assisted the VA. · P4 denied taking the VA’s money. The G provided the following information: · Every month the G would drop off $140 in cash for the VA at the facility. The money would be given to a staff person which was generally P2. The VA had a goal to save money and opened a bank account with savings and checking. At the facility, the VA would keep cash in three envelopes which were labeled, “personal spending,” “social outings,” and “personal care.” Each month the VA would get to decide which funds went into each envelope and how much was deposited into the VA’s bank accounts. · In November 2025, P2 told the G that the VA’s “personal outings” or “social outings” money was low on funds. The VA had not been going on as many outings as the VA had done when the VA lived with the G, so the G was not sure how the VA had spent so much money. P2 said that the VA had not been going out because the VA was low on funds. The G told P2 that the VA had gift cards in the VA’s room that the VA could use and P2 told the G that the VA “lost those” (note: the G said that the VA had “close to $200” in gift cards that the VA had when the VA moved into the facility in April 2025. The gift cards were kept in the VA’s room and were not tracked so it was unknown what the actual amount was that was spent or the VA still had). The G asked for the VA’s spending report to be sent to him/her so s/he could see where the VA had spent money and if the VA needed more funds than what was budgeted. · On an unknown date following the conversation with P2, the G asked the VA if the VA needed help cleaning the VA’s room to look for the gift cards. The VA declined and when the G asked the VA what happened to the gift cards, the VA said, “I don’t know what happened to them.” · In early January 2026, the G asked P1 to send the VA’s spending report as s/he still had not received one from the facility. P1 told the G that s/he was “behind on stuff” but would get the spending reports to the G as soon as s/he could. The G had still not seen the VA’s spending reports as of when s/he spoke to this investigator and said that s/he was “frustrated.” P6 provided the following information: · Two or three weeks prior to February 25, 2026, the VA had money go missing. The day prior to finding out the VA’s money was missing, P6 worked a shift and was told by P2 that s/he would take the VA to the bank the following day. P6 took the VA to a local game store and told the VA about the plan to go to the bank. The VA was excited to get money as the VA had not gone on many outings in the prior month due to activity in the community. · When P6 arrived for his/her shift the following day, P6 went to the staff office but could not find the key to the safe. P6 called P2 and P2 told P6 that the VA’s money was taken and that it was unknown who took it. P2 told P6 to keep it “on the low” and not tell anyone that the VA’s money was missing. P2 told P6 that the VA would not be going to the bank and to “make something up” to tell the VA as to why. P6 told the VA that the facility vehicle needed an oil change. The VA was “really upset” when P6 told the VA. · The VA’s money was kept in a keyed safe in the staff office. The staff office was accessible to all staff and the key to the safe was kept in the staff office. There was a financial book where the VA’s money was tracked. The ledger had three categories for cash. One category was called “personal needs” but P6 did not remember the names of the other two. The VA had a bank account and most of the VA’s purchases the VA made were with the debit card. The bank account transactions were tracked on a separate ledger which staff would enter transactions and balance based on the previous balance recorded. The VA and a staff person would fill out the respective ledger and put the receipt in the financial book. The VA’s money was only counted when the VA made a purchase. P6 did not remember the last transaction s/he made with the VA and estimated that the last time s/he took the VA to the bank was between October and early December 2025. · P6 denied taking the VA’s money. P3 provided the following information: · On February 3, 2026, P3 was notified by either P1 or P2 that the VA was missing over $200. The VA’s money was kept in a locked staff office in a keyed safe. All staff persons knew the access code to the staff office and the key to the safe was kept in the staff office. · The VA received $30 in cash weekly and needed assistance with management of personal spending funds. Receipts were to be obtained for any purchases over $10. The VA did not “always” provide receipts when the VA made purchases. · The VA’s money should be counted by staff persons every time money was taken out of the safe. P1 and P2 were to complete a Cash Resource Record for the VA every month which documented all the transactions that the VA made in a month. The last completed Cash Resource Record for the VA was completed for June 2025. P3 audited the financials at the facility once a year and that was completed in July 2025. · P3 denied taking the VA’s money. P5 provided the following information: · The VA had three different ledgers for cash that was stored in a green binder in the staff office. The ledgers were for “allowance,” “personal needs,” and “social outings.” When the VA spent money, the VA would get a receipt and that would be put into the binder that was stored in the staff office. All transactions were recorded on their respective ledger, and any leftover cash was put into a pencil pouch for the VA in the keyed safe. · On January 31, 2026, P5 assisted another individual supported with getting their card from the safe. P5 went to the office and saw that the key to the safe was still in the safe keyhole. P5 thought it was “weird” as the VA and the other individual who stored money in the safe, had not gone out to spend money due to the recent activity in the community. P5 grabbed the other individual’s card from their pencil pouch but did not go into the VA’s pencil pouch. P5 asked P2 about the key being left in the safe and was told that the other individual’s phone was put in the safe at night and that the key must have been left in the safe when the phone was taken out. · P5 denied taking the VA’s money. P7 provided the following information: · The VA’s money was kept in a keyed safe in the staff office. The staff office was accessed with a code that only staff persons knew. The key to the safe was kept in the staff office and was labeled “safe key.” · When the VA made a purchase or deposit into the bank, the transaction was documented in a financial book, and the receipt was put in an envelope that was kept in the safe. If it was a cash transaction, money would be counted and balanced. If it was a debit card purchase or deposit, the amount would be recorded in the financial book. P7 was newer to the facility and while present for a few purchases that the VA made, another staff person documented those transactions. · P7 denied taking the VA’s money. Facility records showed that P1-P7 were trained on the VAs plans, the facility’s Management of an Individual’s Monetary Resources policy, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Information provided was consistent that the G would bring $140 each month and that cash would be placed in one envelope labeled “allowance.” Each week, the VA would get $30 that would be taken out of the “allowance” envelope with $5 going into the “personal needs,” $5 going into “social outings,” and $20 that was deposited into the VA’s checking and/or savings account. The VA’s money was stored in a keyed safe in the staff office. All staff persons had the access code to enter the staff office and the key to the safe was stored on a hook in the staff office. On February 2, 2026, P2 and P4 went into the staff office to prepare the VA’s money for a deposit into the bank the following day. All three envelopes and the cash inside were missing. On February 3, 2026, P2 told P1 that the VA also had two gift cards that equaled $20 that were also missing from the safe. Due to activity in the community, the VA had not gone out in the community to make purchases or deposit cash into the bank. The last transaction prior to February 2, 2026, was on January 11, 2026. Given that the VA’s cash was stored in a locked staff office that all staff persons had the code to enter and therefore the safe and the key to the safe where the VA’s cash and gift cards were kept, and that the VA needed staff assistance to assist with tracking transactions and cash management, 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 all staff persons had access to the locked staff office and therefore also had access to the safe and key to the safe that stored the VA’s cash and gift cards, and that all staff persons denied taking the VA’s money, it was not determined who took the VA’s cash and gift cards. 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 policies and procedures were adequate but not followed. The VA was to be reimbursed $246.60 in cash and $20 for the gift cards that were missing. Staff persons were to be retrained on “tracking transactions” and counting funds for every transaction. “Excess funds will be kept in a separate lock box with limited staff access.” Staff were to be retrained on the Reporting of Maltreatment of Vulnerable Adults Act. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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