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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: 1123293-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Elisa.Montgomery@state.mn.us Suspected Maltreatment Reported: Allegation One: A vulnerable adult (VA) was receiving a GLP-1 injection for appetite suppression causing the VA to lose too much weight. Allegation Two: Staff persons did not assist the VA with getting dressed and the VA sat on his/her bed unclothed with no sheets on his/her mattress. Allegation Three: The VA’s clothing and cash went missing. Allegation Four: Staff persons yelled at the VA. Date of Incident(s): Unknown Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2); and subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on January 20, 2026; from documentation at the facility; and through four interviews conducted with three facility staff persons (P1-P3), and the VA’s family member (FM). The VA met with this investigator but due to the VA’s diagnoses, s/he was not able to provide information that was pertinent to the incidents outlined in this report. The VA was not subject to guardianship and was diagnosed with hypertensive heart disease, a history of coronary bypass, and cerebrovascular disease with acute ischemic stroke causing short-term memory loss. The VA was diagnosed with Type 1 diabetes and received blood glucose monitoring and insulin on a routine basis. The VA liked watching TV and spending time with family. All staff person’s interviewed were trained on the VA’s plan of care and the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: The VA was receiving a GLP-1 injection for appetite suppression causing the VA to lose too much weight. The VA’s Master Care Plan said that the VA “forgets from one hour to the next that [s/he] ate a meal.” The VA would “request meals from different staff and even other residents.” Staff persons tracked the VA’s food intake and offered the VA meals at each mealtime and a snack in the afternoon and evening. Staff persons documented the food the VA ate in a “food journal”. If the VA requested additional meals within an hour of his/her previous meal, staff persons redirected the VA to a different activity. The FM said s/he was concerned that the VA was not eating on a regular basis, and the VA told the FM during phone calls that s/he was not receiving meals. The FM did not know why the VA was receiving the GLP-1 injection but had not expressed his/her concerns to the facility. P1 provided the following information: · The VA was diabetic and was prescribed a GLP-1 injection (medication to regulate blood sugar, reduce appetite, and support weight management). The VA was prescribed this medication for his/her diabetes diagnosis and not for appetite suppression. · The VA routinely attended scheduled appointments with a physician specializing in the VA’s diabetes diagnosis. The physician did not express concerns related to the VA losing weight or losing weight too quickly. · A nurse came to the facility once per week and weighed the VA. The nurse had not expressed concerns related to the VA’s weight. P2 provided the following information: · P2 was not aware of a GLP-1 injection for appetite suppression. The VA was only administered medications related to his/her diagnoses of diabetes via injection. · The VA had a diagnosis that caused short-term memory loss and often forgot when s/he ate and asked for more food or meals consistently. P2 and other staff persons documented the amount of food the VA ate during meals and snacks. · The VA’s food intake was documented in a “food journal” and contained what types of foods the VA ate during the meal or snack and how much of the meal or snack the VA ate. The VA consistently ate all his/her meals/snacks. P3 was not aware of concerns related to the VA’s medications for treatment of the VA’s diabetes diagnosis. The VA’s Medication History showed the VA was prescribed injectable Ozempic (medication used to lower blood sugar levels and promote weight loss) 0.25 milligrams (mg) to be taken once weekly for four weeks then increase to 0.5mg once weekly. Resident Notes showed that from December 1, 2025, through January 29, 2026, on a routine basis, the VA was administered medications related to his/her diagnoses by staff persons and was served breakfast. Staff persons completed laundry and assisted the VA to medical appointments. The VA interacted with staff persons and watched TV in the living room area or in his/her bedroom. The VA asked for snacks throughout the day, and staff persons provided them to the VA. The VA routinely ate the meals that were prepared for him/her. When the VA was in his/her bedroom for an extended period of time during daytime hours, staff persons checked on the VA hourly. Conclusion for Allegation One: The VA told the FM that the VA was not eating and/or receiving regular meals at the facility. The FM had concerns that the VA was receiving GLP-1 injection. P1-P2 provided consistent information that that the VA was prescribed a GLP-1 injection from his/her physician related to the VA’s diagnosis of diabetes and that the VA often forgot when s/he last ate a meal. The VA’s weight was checked at the facility weekly, and the nurse did not have any concerns. The Master Care Plan showed the VA often forgot that s/he had eaten a meal and requested meals after s/he ate. Staff persons offered the VA regular meals and snacks throughout the day. Staff persons documented the food the VA ate in a “food journal”. Resident Notes from the facility showed that the VA was given meals three times per day and two snacks per day. Given the VA was prescribed the GLP-1 medication by his/her doctor for his/her diagnosis of diabetes, that the facility monitored the VA’s weight, and that facility documentation showed that staff persons provided the VA with three meals and snacks daily, there was a preponderance of the evidence that neglect did not occur. It was determined that neglect did not occur (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). Allegation Two: Staff persons did not assist the VA with getting dressed and the VA sat on his/her bed unclothed with no sheets on his/her mattress. The FM said s/he visited the VA at the facility on an unknown date and saw the VA sitting on his/her bed, not clothed from the waist down with no sheets on the bed. The FM later learned that the VA’s clothing was “limited,” so the FM purchased more clothing for the VA. The FM was aware of another time on an unknown date, another family member visited the VA around 1:00 p.m. and the VA was sitting on his/her mattress without sheets in a t-shirt and no pants. P1 said that around January 14, 2026, P1 was told by the FM that the VA’s mattress required a mattress protector. P1 purchased a mattress protector and put it on the VA’s bed. The VA had a history of incontinence. Staff persons regularly changed the VA’s bedding, but the VA did not have extra sheets for his/her bed. Additional sheets were purchased for the VA’s bed sometime in January, 2026. P2 provided the following information: · The VA had a history of incontinence so P2 washed the VA’s bedding approximately two to three times per week. When P2 washed the VA’s bedding s/he put clean bedding on the VA’s mattress. · On one occasion, P2 remembered the VA being in his/her bedroom unclothed. The VA was incontinent so P2 assisted the VA with cleaning him/herself and cleaning the VA’s bedroom floor. · P2 did not recall any times when staff persons purposefully left the VA unclothed in his/her bedroom on a mattress without sheets. P3 said the VA had a history of incontinence and had his/her sheets cleaned a “minimum” of three times per week. The VA had extra sheets to use when other sheets were being washed. Conclusion for Allegation Two: The FM said that on two occasions, the VA was found undressed sitting on his/her bed which did not have sheets on it. At some point, the FM learned that the VA needed more clothing, so s/he purchased more clothing for the VA. P1-P3 said the VA had a history of incontinence and staff persons routinely changed/washed the bedding. At some point P1 was informed the VA’s mattress required a mattress protector and that s/he needed extra sheets. P1 purchased both the mattress protector and additional sheets for the VA’s bed. Extra sheets and bedding were at the facility for the VA to use when his/her bedding was being washed. Although the VA was found undressed on his/her bed on two occasions with no sheets on his/her bed, given that the VA had a history of incontinence, that staff persons changed/washed the VA’s bedding regularly, and that when P1 was informed that there was not a mattress pad protector or extra sheets available, s/he purchased them, there was not a preponderance of the evidence whether staff persons failed to provide the VA with care and services necessary to maintain his/her health or safety. 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). Allegation Three: The VA’s clothing and cash went missing. The VA’s Master Care Plan said the VA was susceptible to financial exploitation and had a representative payee. The facility was not authorized to assist the VA in safekeeping of cash. If staff persons observed theft or financial exploitation, staff persons called 9-1-1 or notified their supervisor. The FM said that on two occasions between November and December 2025, the FM gave the VA $250 and $300 in cash to an unknown staff person. The facility did not keep track of the funds as the VA was spending the cash. The FM believed the facility was responsible for tracking the VA’s finances. The FM was concerned the VA’s clothing was going missing because when the FM went to visit the VA, the VA was missing clothing that was purchased for the VA before s/he went to the facility. The FM purchased more clothing for the VA and labeled the clothing. Petty Cash Logs and receipts from the facility provided the following information: · On August 5, 2025, the VA had a cash deposit of $150, on September 10, 2025, the VA had an ending balance of $2.03. The facility kept receipts for all purchases made. · On November 6, 2025, the VA had cash deposit of $250.00. Transactions through January 15, 2026, showed the VA had a balance of $181.13. The facility kept receipts for the purchases that were made during that time. · There was no transaction records provided to this investigator for September and October 2025. P1 provided the following information: · The VA had a representative payee who assisted the VA with managing payments for rent but did not disburse the VA’s cash funds. The FM gave the VA cash for spending. The facility kept receipts from purchases for the representative payee to review. P1 was not aware of any missing cash as the facility did not have authorization regarding safekeeping of cash funds for the VA. · The VA’s cash was kept in a locked closet in a binder. The VA’s receipts for purchases were also stored with the VA’s cash. · Due to the VA’s history of incontinence, there were times when staff persons disposed of the VA’s soiled clothing if it could not be cleaned. Staff persons attempted to soak soiled clothing in a basin in the laundry room but there were times when the clothing was too soiled to soak or wash in the washing machine. The VA’s family purchased additional clothing for the VA as needed. P2 said s/he did not assist the VA with cash or other financial matters. The VA had a history of incontinence and often soiled his/her clothing. When this occurred, P2 took the VA’s clothing to the laundry room to be washed. P2 was not aware of any clothing that went missing. P3 provided the following information: · On one occasion the FM came to the facility and mentioned the VA was missing some clothing. When the VA arrived at the facility, s/he did not have much clothing, and the FM brought more clothing for the VA. P3 did not have any further information regarding missing clothing. · P3 did not assist the VA when s/he used cash but was aware of the procedure. When the VA went into the community, the VA held onto and spent his/her cash funds. Staff persons obtained a receipt for purchases and put it in a locked safe that was located in a locked closet at the facility. Conclusion for Allegation Three: Sometime between November and December 2025, the FM gave the VA $250 and $300 and was concerned the facility was not keeping track of the funds as the VA was spending the cash. The FM also had concerns that some of the VA’s clothing was missing. P1-P3 provided consistent information that due to the VA’s history of incontinence, there were times when staff persons disposed of the VA’s soiled clothing. Staff persons attempted to soak soiled clothing in a basin in the laundry room but there were times when the clothing was too soiled to soak or wash in the washing machine. The FM provided the VA with additional clothing as needed. P1-P3 were each not aware of any missing cash. P2 and P3 both did not assist the VA with financial matters. The facility did not have authorization regarding safekeeping of cash funds for the VA. When the VA went into the community, the VA held onto and spent his/her cash funds. Staff persons obtained a receipt and put it in a locked safe that was located in a locked closet at the facility that the VA did not have access to. The Master Care Plan showed the facility was not authorized to assist the VA in safekeeping of cash. Petty Cash Logs showed cash deposits of $150 and $250 on August 5, 2025, and November 6, 2025. The facility maintained receipts for cash purchases that were made. Given that staff persons said there were times that some of the VA’s clothing was disposed of because they were soiled, that the facility maintained records and receipts of purchases made by the VA, and that although the amounts differed from what the FM said s/he provided, without any further information there was not a preponderance of the evidence whether the VA’s funds were used or withheld without the VA’s 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). Allegation Four: Staff persons yelled at the VA. The FM had concerns that due to “language barriers”, the VA was not able to understand what staff persons were verbally expressing to the VA on occasion. There were no concerns related to staff persons yelling at the VA expressed by the FM. P1-P3 did not have information related to any staff person yelling at the VA and denied yelling at the VA. P2 said all staff persons were “friendly” and “hospitable” towards the VA and that the VA was “easy to get along with.” Conclusion for Allegation Four: Information was received that staff person’s yelled at the VA. The FM had not heard any staff persons yelling at the VA. P1-P3 denied yelling at the VA and had not heard any other staff persons yelling at the VA. Given that each P1-P3 denied yelling at the VA, that each had not heard any other staff persons yell at the VA, and without any further information that the VA was yelled at by staff persons, there was a preponderance of evidence that emotional abuse did not occur. It was determined that emotional abuse did not occur (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Action Taken by Facility: The facility completed an internal review and determined policies and procedures were adequate and were followed. Staff persons working at the facility were re-trained regarding ensuring the VA’s sheets are washed and spare sheets are put on the bed and additional training related to the VA’s short-term memory loss was completed to ensure staff persons were able to learn effective communication techniques and navigate the VA’s behavior. Action Taken by Department of Human Services, Office of Inspector General: On July 31, 2026, the facility was issued a Correction Order for not obtaining authorization to assist with safekeeping of client funds.
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