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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: 1071944-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP1) used a vulnerable adults (VA’s) debit card to make multiple cash withdrawals at a casino. It was reported that SP1 used the VA’s debit card to make cash back withdrawals at Walmart. It was reported that another staff person (SP2) used the VA’s debit card to order sports game tickets for the VA, SP1, and another staff person (SP3). Date of Incident(s): Multiple from July 2025 through February 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 for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through seven interviews conducted with three facility staff persons (SP1-SP3), two supervisory staff persons (P1, P2), the VA, and the VA’s family member (FM). The VA was diagnosed with major depressive disorder and schizotypal personality. The VA enjoyed spending time with family, listening to music, going for walks, and watching sports games. The VA was enjoying his/her retirement and had a goal to attend a Vikings football game and attend family vacations and events. The VA’s Financial Authorization indicated s/he did not require assistance from the facility or staff persons with the management of his/her cash, checking/savings and other bank accounts, monitoring or documentation of trust funds or special accounts, and did not have a representative payee. The VA did not require additional approval to make a high dollar purchase. The facility’s Management of an Individual’s Monetary Resources policy stated, “The Company or its employees will not borrow from, loan to, purchase personal items from, or sell any items or personal services to the individuals. The Company or its employees will not require a person to purchase items for which the program is eligible for reimbursement or use a person’s funds to purchase items for which the program is already receiving public or private payments,” and “There will be no co-mingling of funds between individuals served, the Company, or employees.” The VA’s Risk Assessment Detail showed that staff persons assisted the VA in managing his/her finances by helping him/her keep track of his/her purchases, helping him/her balance his/her checkbook, and helping him/her reconcile his/her checkbook with his/her bank statement. The VA could not recognize mismanagement of his/her finances. The VA’s checkbook was checked weekly by a supervisor and reconciled monthly by a supervisor. If mismanagement of his/her finances was noted, staff persons reported to proper authorities. P1 provided the following information: · The VA needed assistance with PIN pads at stores so it would not be unlikely for SP1 and other staff persons to know the VA’s PIN number for his/her debit card. Staff persons held onto the VA’s debit card when taking him/her shopping but the VA kept his/her cash funds in his/her wallet. · P1 gathered receipts from the VA monthly and compared them to the bank statements to ensure funds were being used as shown on the receipts. If there were no receipts for a transaction, P1 followed up with the VA to ensure the transaction was made by the VA. If the VA could not remember, P1 followed up with staff persons who worked on the day the transaction was made. The FM thought the VA would likely give staff persons his/her PIN number for his/her debit card if s/he was asked. The VA would likely “borrow” money to a staff person and would not understand that s/he should not “borrow” money to a staff person. The FM did not have prior concerns with the facility. SP1-SP3, and P1 were trained on the VA’s plan of care and on the Reporting of Vulnerable Adults Act. P2 was trained on the Reporting of Vulnerable Adults Act. All staff persons interviewed were trained on the facilities policies and procedures. Regarding the use of the VA’s debit card to make withdrawals at the casino: The VA provided the following information to LE and to this investigator: · The VA and SP1 went to the casino about once a week. On February 12, 2026, at around 9 a.m., SP1 took the VA to the bank where the VA withdrew $500. SP1 went into the bank with the VA and watched the VA make the transaction at the bank. The VA put $200 in his/her wallet and gave $300 to SP1 to hang on to and SP1 and the VA went to the casino. · SP1 held onto the VA’s debit card and the VA did not make any withdrawals at the casino. SP1 gambled at the casino with his/her own money and won money while at the casino but the VA did not know how much. SP1 and the VA returned from the casino around 5:00 p.m., and the VA had $200 in cash when s/he got back to the facility which was money the VA won at the casino. · LE informed the VA that two separate withdrawals of $400 each were made at the casino on February 12, 2026. The VA denied making withdrawals at the casino and expressed s/he only withdrew money at the bank. · The VA did not see SP1 go to the ATM at the casino and SP1 remained by the VA while at the casino. The VA did not have concerns SP1 used his/her debit card to withdraw cash. · SP1 held onto the VA’s debit card while at the casino and other staff persons kept the VA’s debit card when out in the community. The VA’s debit card was stored in the staff office at the facility. P1 provided the following information: · On February 12, 2026, P1 took the VA to a scheduled appointment and returned to the facility with the VA. P1 reminded the VA that s/he had another appointment that P1 would take him/her to. The VA acknowledged P1 and went to his/her bedroom and P1 went to the staff office in the facility. · Later that day P1 looked for the VA to go to his/her second appointment but found that SP1 had taken the VA to the casino. P1 called SP1 to come back to the facility with the VA since the VA had a scheduled appointment. SP1 told P1 that they would not be able to get back in time for the VA’s scheduled appointment so P1 rescheduled the appointment. SP1 and the VA left around 11:00 a.m. and returned around 9:00 p.m. · P1 was concerned that SP1 was taking money from the VA because the VA was vulnerable to financial exploitation and SP1 was taking the VA to the casino more frequently without the VA’s housemates. The VA did not mention to P1 that s/he planned to go to the casino with SP1 on February 12, 2026, and the VA was very detailed when it came to making his/her plans for the week. · P1 reviewed the VA’s banking statement and saw that on February 12, 2026, there was over $1,000 in withdrawals. P1 asked the VA if s/he knew how much s/he spent at the casino, and the VA did not recall. The VA’s bank statements showed withdrawals on February 12, 2026, of $500 and $403 (with an additional $2.50 for off-site ATM use). On February 13, 2026, there was a withdrawal of $409.95 from the casino (likely made on February 12, 2026). · P1 followed up with SP1 regarding the transactions and SP1 told P1 that the VA only withdrew $500 from the bank. P1 asked SP1 if s/he saw the VA make additional withdrawals at the casino and SP1 repeated the VA only withdrew $500. · P1 knew that the VA preferred to go to the bank teller to withdraw cash since s/he did not know how to use an ATM. SP1 provided the following consistent information to this investigator and LE: · On February 12, 2026, SP1 worked at the facility. SP1 did not recall what time s/he left with the VA to go to the casino but guessed it was “around noon”. · The VA withdrew an unknown amount of cash from the bank teller. SP1 was talking on his/her phone in the car and did not go inside the bank with the VA. · While at the casino, SP1 “borrowed” $200 from the VA to gamble but paid back the VA $200 the same day. · SP1 held onto the VA’s debit card and some of his/her cash. SP1 gave the VA cash in $20 increments so the VA could continue to gamble. · SP1 denied using the VA’s debit card at the casino ATM to withdraw cash but said the VA used his/her debit card and ID to withdraw cash from the casino cashier. · SP1 said there were times when s/he took the VA’s cash out tickets while at the casino and switched the VA’s cash out tickets with SP1’s cash out tickets. SP1 was not sure the total amount that was switched. · SP1 initially denied knowing the VA’s debit card PIN number but then said that on one occasion, while at the casino, the VA asked him/her to go to the ATM and withdraw $400. SP1 withdrew the cash and gave it to the VA. SP1 denied withholding and keeping any of the VA’s cash that was withdrawn from the ATM. · SP1 did not recall receiving training regarding how to handle the VA’s funds and was not familiar with training related to facility policies and procedures. Camera footage from the casino on February 12, 2026, provided the following information: · SP1 was seen on video footage wearing two different purses. SP1 walked away from the VA who was seated at a slot machine and walked towards an ATM. · SP1 took the VA’s debit card out of the top purse and put the card into the ATM. SP1 made selections and entered the PIN number into the PIN pad and received $200 in hundred-dollar bills and $200 in twenty-dollar bills for a total of $400. SP1 put the money into the top purse. (Note: ATM metadata showed the transaction occurred on February 12, 2026, at 2:59 p.m. Receipts showed an additional $3 withdrawal fee.) · SP1 walked over to the slot machine the VA was seated at but did not give the VA any money at that time. · SP1 went up to the ATM machine a second time. SP1 put the VA’s debit card into the ATM machine, made selections, and entered the PIN number into the PIN pad but did not receive any cash at that time. SP1 put the debit card back into his/her purse. (Note: ATM metadata showed attempts for withdrawals on February 12, 2026, at 5:41 p.m. A withdrawal of $400 was declined for insufficient funds. A $300 withdrawal was declined for insufficient funds. A withdrawal of $200 was declined for invalid PIN). · The VA and SP1 then went to the casino cashier at 5:46 p.m. The VA handed the casino cashier his/her ID and SP1 gave the casino cashier the VA’s debit card. SP1 made selections on the PIN pad and the VA entered a PIN number into the PIN pad. · The casino cashier laid down the VA’s debit card and ID. The VA grabbed his/her ID card and SP1 grabbed the VA’s debit card. The cashier counted $200 in hundred-dollar bills and $200 in twenty-dollar bills for a total of $400. SP1 attempted to pick up the cash from the counter but the VA took the cash and SP1 and the VA walked away. (Note: Receipts showed an additional $9.95 withdrawal fee). Additional LE information and Shift Notes from the facility provided the following: · On July 5, 2026, a withdrawal from the casino ATM was made using the VA’s debit card totaling $403. Facility documentation showed SP1 took the VA to the casino. It was unknown if the VA was given the withdrawn funds. The VA’s bank statement showed a $500 withdrawal from savings on February 12, 2026. · On July 20, 2025, a withdrawal of $300 was made using the VA’s debit card. Facility documentation showed SP1 took the VA to the casino and the VA ate at the casino restaurant on two occasions. It was unknow if the VA used all the withdrawn funds at the casino. Regarding the use of the VA’s debit card to make cash back withdrawals at Walmart: The VA denied making cashback withdrawals at Walmart because s/he did not know what that was and did not know how to use an ATM. LE information provided the following: · The VA’s transaction history from July 2025, contained transactions that did not align with the VA’s typical spending. The VA routinely withdrew $100 from his/her bank account weekly on Monday. It was out of the normal for the VA to make a cash back withdrawal from Walmart. · On July 11, 14, and 21, 2025, cash back withdrawals were made at Walmart. Each receipt showed that a Milky Way candy bar was purchased and $100 in cash back was received. SP1 worked at the facility on the days the transactions were made. · On July 11, 2026, the VA made additional purchases at Walmart that were not believed to be “suspicious,” and the VA also made a cash back withdrawal from Walmart on July 7, 2025. The additional cash back withdrawal on July 11, 2025, was “suspicious” due to the VA already withdrawing cash four days prior. · On July 14, 2025, the VA made an additional purchase at Walmart that was not believed to be “suspicious,” and the VA received $20 cash back with that purchase. An additional cash back withdrawal that was also made on July 14, 2025, was “suspicious” given the VA had made the same cash back withdrawal and candy bar purchase four days prior. · On July 21, 2025, the VA made a withdrawal from his/her bank account of $380 prior to going to Walmart. The cash back withdrawal was “suspicious” due to the previous transactions matching the ones made on July 11 and 14, 2025 (candy bar purchase with $100 cash back). SP1 said s/he did not tell the VA to make cash back withdrawals at Walmart and did not see the VA make cash back withdrawals. SP1 assisted the VA with making purchases at Walmart by inserting the VA’s debit card into the card reader, going through the prompts on the keypad, and then the VA entered his/her PIN number. SP1 denied knowing the VA’s PIN number and/or taking the VA’s money for him/herself. Shift Notes showed that on July 11 and 14, 2026, SP1 took the VA shopping at Walmart. Review of the VA’s receipts for the dates showed the following: · July 11, 2025, a Missing Receipt Voucher showed a purchase for a Milky Way candy bar was made but there was nothing documenting the $100 cashback withdrawal. There were no signatures on any of the Missing Receipt Vouchers from the VA, so it was unknown if the VA was aware of the purchases that did not have receipts. · July 14, 2025, showed a receipt at 10:50 a.m., for a Milky Way candy bar with $100 cashback. There was another receipt for snacks and two Milky Way candy bars with $20 cashback. · July 21, 2025, showed a receipt at 11:52 a.m. for Milky Way candy bar with $100 cashback. There was another receipt at 12:17 p.m., for self-care items, clothing and snacks. Regarding the use of the VA’s debit card to purchase sports game tickets: The VA remembered attending a professional sports game but was not able to provide additional information. SP2 provided the following information: · The VA wanted to go to a professional sports game. SP2 asked the VA’s case manager (CM) if tickets for staff persons could be purchased using the VA’s funds. The CM told SP2, “No.” SP2 contacted P2 asking if the facility could purchase sports game tickets for staff persons to attend with the VA. P2 informed SP2 that due to the amount, the facility would not be able to purchase the tickets. · SP2 asked SP1 and SP3 if they were able to pay back the VA if the VA used his/her debit card to purchase game tickets and SP1 and SP3 agreed they would be able to pay back the VA. SP2 ordered the tickets online using the VA’s debit card. · SP2 ordered five tickets using the VA’s debit card. SP2 only meant to order three tickets but did not see that s/he had five tickets in the online cart prior to checking out. SP2 attempted to resell the tickets but was unable to get full price back so s/he did not resell the tickets. The VA was not aware SP2 purchased two additional tickets. SP2 did not inform his/her supervisor that two additional tickets were purchased. · SP2 was aware that facility policy did not allow staff persons to borrow money from individuals but SP2 “felt bad” the VA was not able to attend a professional sports game like s/he wished. SP2 also wanted to ensure that the VA, SP1, and SP3 could all sit together at the sports game so that is why SP2 used the VA’s debit card to purchase the tickets. SP1 said that on February 2, 2026, SP1, SP3, and the VA went to a professional sports game. SP1 did not purchase the tickets but understood that SP2 ordered the tickets using the VA’s debit card. SP2 told SP1 that s/he had to pay back the VA using cash. SP1 had not paid the VA back at the time of this report. SP3 provided the following information: · SP2 asked SP3 and SP1 if they were able to take the VA to a professional sports game and if they were able to pay back the VA the price of the ticket if SP2 ordered the tickets using the VA’s debit card. SP1 and SP3 agreed so SP2 ordered the tickets. Each ticket cost $137. · On February 2, 2026, around 2 p.m., SP1 and SP3 left with the VA to go the game and returned around 1 a.m. · SP3 was aware of the facility’s policy regarding borrowing funds from the VA but was told by SP2 that if there was a “paper trail” it was okay to use the VA’s debit card to purchase the game tickets if SP3 paid the VA back. · Around February 11 or 12, 2026, SP3 paid the VA $137 in cash and took the VA to the bank to deposit the cash so there was record of SP3 paying back the VA. Information from Customer Sales and Service showed that two of the tickets that the VA purchased were not scanned/used for the game on February 2, 2026. Emails between SP2 and the CM provided the following information: · On January 16, 2026, SP2 emailed the CM about ideas for the VA’s spenddown. SP2 said the VA wanted to attend a professional sports game and would purchase tickets for staff persons. · On January 22, 2026, the CM responded that “[the VA’s] money should not be used to purchase game tickets for staff.” P2 said s/he was aware the VA wanted to attend a professional sports game but was not aware that SP2 used the VA’s debit card to order tickets for staff persons. P2 did not authorize SP2 to use the VA’s debit card to purchase the tickets. The VA’s bank statements showed a deposit of $140 made on February 9, 2026. Relevant Minnesota Statues and Rules: Minnesota Statues section 245D.06, subdivision 4, paragraph (a) states, whenever the license holder assists a person with the safekeeping of funds or property, the license holder must obtain written authorization to do so from the person or the person’s legal representative and the case manager. Conclusion: A. Maltreatment: Information from SP1-SP3, P1, P2, the FM, and the VA was consistent that the VA did not keep his/her debit card on his/her person in the community or prior to making purchases. Staff persons held onto the VA’s debit card and gave the VA his/her debit card when making a purchase. SP1 denied knowing the VA’s PIN number but information was consistent that if a staff person were to ask the VA his/her PIN number, the VA would provide it to staff person’s. Facility information showed receipts from purchases were maintained and kept. A financial tracker of the VA’s spending was completed that included withdrawals and deposits from the VA’s bank accounts and bank statements that were received via mail. If receipts were missing, Missing Receipt Vouchers were completed and added to the VA’s financial tracker. Regarding the use of the VA’s debit card to make withdrawals at the casino: The VA provided information that s/he went to the casino with SP1 on February 12, 2026. Prior to going to the casino, the VA withdrew $500 from the bank teller and gave SP1 $300. The VA denied making any withdrawals from the ATM at the casino. SP1 denied using the VA’s debit card to make a withdrawal from the ATM at the casino but was observed on video using the VA’s debit card to withdraw $400. SP1 was not observed giving the VA any cash from the withdrawal. SP1 and the VA were observed on video making another withdrawal of $400 from the casino cashier. SP1 acknowledged that s/he “borrowed” $200 from the VA but paid the VA back $200. SP1 also said there were times when s/he took the VA’s cash out tickets while at the casino and switched the VA’s cash out tickets with SP1’s cash out tickets. SP1 was not sure the total amount that was switched. Although SP1 denied taking any of the VA’s money, given that camera footage from the casino showed SP1 using the VA’s debit card and PIN number to withdraw $400 without the VA, that SP1 said s/he “borrowed” $200 from the VA but paid the VA back, that SP1 said s/he switched cash out tickets with the VA, and that the VA denied making any withdrawals from the ATM at the casino, there was a preponderance of the evidence that the VA’s funds were willfully used or withheld, or disposed of in the absence of legal authority. Regarding the use of the VA’s debit card to make cash back withdrawals at Walmart: The VA denied making cashback withdrawals at Walmart because s/he did not know what that was and did not know how to use an ATM. SP1 denied telling the VA to make cash back withdrawals at Walmart. SP1 said s/he assisted the VA when making purchases at Walmart by inserting the VA’s debit card into the card reader and the VA entered his/her PIN number. SP1 denied taking the VA’s money for him/herself. The VA’s transaction history, Shift Notes, and receipts from July 2025, showed that on each July 11, 14, and 21, 2025, a $100 cash back withdrawal was made at Walmart after purchasing a candy bar. On both July 14 and 21, 2025, an additional purchase for personal care items and other items was made. On July 11, 2025, the VA made a large cash withdrawal at the bank before getting more cash back at Walmart. SP1 worked at the facility and took the VA shopping on the days the transactions were made. Although SP1 denied using the VA’s debit card for cashback purchases at Walmart, given consistent information was provided that the VA did not hold onto his/her debit card and SP1 assisted the VA with keypad selections; held onto the VA’s debit card; and knew the VA’s PIN number there was a preponderance of the evidence that SP1 willfully used and or disposed of the VA’s funds in the absence of legal authority. Regarding the use of the VA’s debit card to purchase sports game tickets: Information was consistent from SP1-SP3 that game tickets were purchased using the VA’s debit card for the VA, SP1, and SP3 and that on February 2, 2026, the VA, SP1, and SP3 attended the game. SP2 said s/he was told that s/he should not purchase tickets for staff persons with the VA’s funds by the CM, but s/he ordered five tickets using the VA’s debit card. SP2 only meant to order three tickets but did not see that s/he had five tickets in the online cart prior to checking out. SP2 attempted to resell the tickets but was unable to get full price back so did not resell the tickets. SP1 and SP3 agreed to pay back the VA back for the price of the ticket. SP3 said that SP2 said it was okay to use the VA’s debit card to purchase the game tickets if SP3 paid the VA back. Around February 11 or 12, 2026, SP3 paid the VA $137 in cash. The VA’s bank statement showed that on February 9, 2026, a deposit of $140 was made. SP1 had not reimbursed the VA for his/her ticket at the time of this report. Given the VA’s funds were used to purchase five tickets to a sporting event that included two tickets for staff persons and two tickets that were not used without the VA’s knowledge or consent, there was a preponderance of the evidence that the VA’s money was willfully used or withheld 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. SP1-SP3 were each trained on the VA’s plan of care, the facilities policy and procedure regarding safekeeping of funds, and on the Reporting of Vulnerable Adults Act. SP1 was observed on video footage using the VA’s debit card to withdraw cash funds from an ATM at the casino and likely made withdrawals of cash funds from Walmart using the VA’s debit card for SP1’s own use. SP1 admitted “borrowing” cash from the VA and switching cash out tickets with the VA at the casino. SP1 also attended a sports game with the VA in which the VA paid for SP1’s ticket. SP2 purchased tickets to a sporting event for two staff persons with the VA’s money even though the CM said that SP2 should not. SP2 accidentally purchased five tickets and did not recuperate the funds of the two extra tickets purchased in error and/or notify his/her supervisor about the error causing the VA to lose the money. Although SP3 paid back the VA, SP1 did not, so the VA purchased three tickets that s/he did not use. SP3 was told by SP2 that the VA purchased SP3’s ticket for the sporting event and that SP3 should pay back the VA for the price of the ticket. SP3 paid back the price of the ticket to the VA. Given that SP3 paid back the VA and that SP2 who was SP3’s supervisor instructed SP3 to do this and SP2 made the purchase, not SP3, SP3’s responsibility was mitigated. SP1 and SP2 were each responsible for the 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 financial exploitation for which SP1 was responsible did not meet the definition of “serious” maltreatment but was “recurring” maltreatment because SP1 made multiple withdrawals and transactions with the VA’s funds on multiple occasions. SP1 was disqualified from providing direct contact services. It was determined that the financial exploitation for which SP2 was responsible did not meet the definition of “serious” and was not “recurring” as it was a single incident. Action Taken by Facility: The facility completed an internal review and determined their policies and procedures were adequate but were not followed. SP1 no longer worked at the facility. Staff persons received retraining regarding Management of an Individual’s Monetary Resources. Action Taken by Department of Human Services, Office of Inspector General: SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal. SP2 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP2 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 SP2. The determination that SP2 was responsible for maltreatment is subject to appeal. On July 29, 2026, the facility was issued a Correction Order for the violations outlined in this report.
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