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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: 1071711-H_CRS (Home and Community-Based Services-Community Residential Setting) 1071691-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) stole clothing from a vulnerable adult (VA). Date of Incident(s): 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 for this investigation was obtained remotely, including documentation from the facility; and through five interviews conducted with two facility supervisors (P2-P3), the VA’s case manager (CM), the VA’s guardian (G), and the SP. The VA was non-verbal and unable to complete an interview. Facility documentation showed the VA appeared to enjoy music, sensory time with weighted blankets, and spending time with family and trusted caregivers. The VA was diagnosed with developmental disabilities and required a 24-hour plan of care with a staffing to client ratio of 1:4. The VA’s documentation provided the VA’s height and weight during his/her intake, but did not provide a clothing size s/he preferred. The VA’s Risk Assessment showed the VA did not have a concept of money, or objects’ monetary value. It was reported that four items belonging to the VA were missing. The items included two matching sets of sweatshirt/sweatpants. During the investigation information obtained was regarding the set which was described as oversized, and the color was described as burgundy with a hot pink stripe. There was very limited information related to the second outfit that had gone missing. The facility completed an Incident Report which provided the following information: · The VA had clothing that went missing some time between late September and early October 2025. · On December 19, 2025, it was observed that the SP was potentially wearing an outfit that was similar to that of the VA’s clothing that went missing, the burgundy sweatshirt and sweat pant set. The SP was working at a different facility location, and a picture was taken of the SP while in the outfit. · The G reviewed the picture of the SP in the alleged outfit, and the G verified the items in the picture were the exact same as the burgundy set that belonged to the VA that was missing. The facility completed an Internal Review which provided the following information: · The facility interviewed a staff person (P1) who said the VA had clothing that was missing, and the clothing was a birthday gift given to the VA by the G. The facility completed a search of the facility including the VA’s bedroom, as well as the bedrooms of the other persons at the facility, but the items were not found. P1 messaged all staff persons who worked at the facility and inquired about the clothing, but the clothing was not located. In or around November 2025, P1 saw the SP in a social media post, and believed the SP may have been wearing the VA’s clothing that had gone missing, however there was not enough of the clothing observed in the social media post to confirm the outfit matched that of the VA’s that had gone missing. P1 informed P2 of the concern, and on around December 18, 2025, P2 observed the SP potentially wearing the VA’s burgundy set that went missing. · The facility’s schedule showed the SP’s last shift at the facility was on October 12, 2025. · The SP denied stealing any item from the VA. The SP stated s/he had multiple track suits, jogging pants, sweatshirts, etc. that s/he purchased over the years. · The facility reimbursed the VA for the missing clothing. The G, P2-P3 provided the following consistent information: · The VA received clothing as a gift in September 2025, and the clothing went missing some time in October 2025. The G said s/he had purchased the item from a large retail store. A receipt for the outfit was not provided to this investigator during the investigation. · A picture of the SP showed s/he was wearing an outfit which matched the description of the VA’s missing clothing provided by P2-P3, and the G. · P3 said the VA and the SP were considered to be similar in physical size. · There was no other staff person alleged to have taken the clothing, and no one had knowledge of the whereabouts of the outfit. The SP provided the following information: · The SP denied stealing the VA’s clothing, and said the last time s/he saw the clothing was when s/he put it in the VA’s closet. The SP said s/he had the same outfit the VA had. The SP said the outfit had been given to him/her by a family member four years ago. The SP added that s/he had worn the outfit to the facility on a day in which the VA was wearing the same outfit, but was unable to remember what staff s/he had worked with that day. · The SP said s/he had only worked at the facility approximately six times, and believed s/he was potentially being blamed for the missing clothing due to his/her “blunt” interactions. · The SP said the VA wore a larger size of clothing than the SP. In July 2025, a background study for the SP was completed and showed the SP’s height and weight and the SP was slightly shorter than the VA, and the SP weighed approximately 20 pounds more than the VA. The CM did not have any information to provide that was related to the investigation. LE was contacted regarding the incident; however, the G did not pursue charges, and the LE case was closed. P2-P3, and the SP completed training on Reporting of Maltreatment of Vulnerable Adults Act and on the facility’s policies and procedures. Conclusion: On December 19, 2025, a picture showed the SP wearing an outfit that was the same as the VA’s outfit that had gone missing in October 2025. Prior to December 19, 2025, P1 believed s/he observed a social media post of the SP potentially wearing the VA’s clothing, but P1 was not able to confirm the outfit as not enough of the clothing was observed in the social media post. The VA was unable to provide information for the investigation, but the G said s/he believed the outfit in the picture was the same as the one s/he had purchased for the VA. After searching the facility the outfit was not found at the facility. There was no other information any staff person was involved in the clothing going missing. The SP denied stealing the clothing from the VA, and provided inconsistent information to the facility compared to that the SP provided this investigator. The SP told the facility s/he owned multiple athletic type outfits, and did not mention when or from whom s/he had received the specific outfit that was captured in the picture. Whereas, the SP told this investigator s/he had received the specific outfit from a family member four years ago. The SP also stated that s/he did not wear the same size clothing as the VA. Information showed the SP worked at the facility until October 12, 2025, and the VA’s clothing went missing sometime in October 2025. The facility was searched but the clothing was not found. The VA and the SP were similar in physical size, and the SP provided inconsistent information, however the SP provided a plausible explanation of owning the same clothing as the VA. Given that the SP denied taking the VA’s clothing and that anyone who had access to the facility potentially had access to the VA’s clothing, there was not a preponderance of the evidence whether the VA’s property was willfully used and withheld in the absence of legal authority. 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.) Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate but not followed. The facility retrained the SP on Maltreatment of Vulnerable Adults Act. The report was not similar to past events. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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