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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: 1110851-HCBS (Home and Community-Based Services) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) shoplifted using a vulnerable adult’s (VA’s) mobility cart while out shopping with the VA, and that during the shopping trip, the SP called the VA “incompetent” and told the VA that s/he was unable to advocate for him/herself in front of grocery store staff persons. Date of Incident(s): June 8, 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 2, paragraph (b), clause (2); 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. 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 July 23, 2026; from documentation at the facility; and through six interviews conducted with a community person (CP), a facility supervisor (P1), a facility staff person (P2), the VA’s case manager (CM), the VA, and the SP. The VA was diagnosed with a traumatic brain injury (TBI), sleep apnea, and generalized anxiety disorder. The VA enjoyed spending time with his/her dog, socializing with people, playing cards, and attending church. The VA’s plans stated that s/he was a “good advocate” for him/herself and wished to have a reliable in-home support worker. The VA’s plans also stated that s/he was typically able to “exercise judgement in navigating social interactions without assistance.” The VA lived in his/her own home and was not subject to guardianship. The VA received 18 hours of individualized home support (IHS) with training services. The services included housekeeping, laundry, accessing the community, assistance with phone use, meal preparation, organization, paperwork, phone use, shopping, and transportation. The VA needed assistance because the VA’s ability to move throughout the home was restricted. The VA’s home had a lot of items on countertops, furniture, and in various rooms, and this made it difficult for the VA to safely and effectively move throughout his/her home. According to the VA’s plans, s/he had “significant problems with short-term memory and organization skills,” which interfered with his/her ability to complete tasks. The VA had a risk of falling due to tripping on things within his/her home. The VA described him/herself as being in “excruciating pain.” Facility documentation showed that the SP was hired on January 15, 2026. The SP was the VA’s main facility staff person, and P2 also worked with the VA on an as-needed basis. P1 stated that the SP and the VA worked with one another to schedule times that the SP would work with the VA. According to P1, P2, the VA, and the SP, when a staff person arrived to work with the VA, s/he had to be within a certain distance of the VA’s home to clock in using an application on their phone.
The SP was not scheduled specific hours and would communicate directly with the VA regarding when the SP would work. The VA was supposed to enter a code on the phone application to approve the hours worked by the SP on the SP’s timesheet, so there was no communication between the facility and the SP when the SP did not work hours s/he told the VA s/he would work. When the SP could not work hours that the SP and the VA scheduled, the SP would tell the VA directly. The VA provided the following information: · On June 8, 2026, the SP and the VA used the VA’s car to go to a grocery store to shop for the VA. While in the store, the SP did some of his/her own shopping, and put a case of bottled water between the VA’s feet on the platform of a store mobility scooter that the VA was using. The VA put a carton of milk there too while shopping but did not specify to this investigator if the milk or water was placed there first. During check out, the VA put the SP’s chicken and chips on the belt. The SP said to the VA, “What do you think you’re doing? Don’t ever touch my stuff! I already paid for that.” The VA was “flabbergasted” and did not know what to say. The VA asked the SP where s/he paid and the SP stated that s/he paid for those items at the deli counter. · During the checkout process, the VA had non-food items to pay for with a medical card. The VA got the food receipt and asked several cashiers to show the VA where the loyalty discounts were taken off the price. The cashiers could not show the VA where the discounts were listed, but said they were on there. The VA again asked the cashiers to point out the discounts. There was also some confusion about whether the non-food items were being scanned properly. The non-food items were then rescanned. During this confusion, the VA forgot to put his/her milk which was on the scooter on the belt, and the SP’s water was also left on the VA’s scooter. The SP was “hurrying” to get out of the store and “rushing” the VA by saying, “Let’s get out of here.” When the VA asked the cashiers for additional clarification about the food and non-food items being rung up correctly, the SP told the VA, “Geez. That’s okay, you don’t need to know.” The VA was taken aback and told the SP that s/he could not speak to the VA in “that manner.” The SP responded that s/he did not talk to the SP in “any way.” · As the SP and VA left the store, the VA noticed s/he did not pay for his/her milk because s/he had not placed it on the belt, and told the SP that the water had not been paid for. The SP responded that s/he “never paid for water” when shopping for groceries. When the VA wanted to pay for his/her milk, the SP said, “Let’s get out of here,” and, “Go, just go.” The VA did not feel like s/he had the freedom to go back into the store. Back in the VA’s car, the VA reviewed his/her receipt and the SP ripped the receipt in half and said, “Oh, just forget about that.” · When the VA drove the SP and VA back to the VA’s house, the VA stopped at the SP’s vehicle, which was parked around the corner from the VA’s home so that the SP could unload his/her own groceries into the SP’s car. The VA parked in his/her driveway and waited for the SP to help unload the groceries. After a while, the SP did not come to the VA’s house and the VA thought that the SP went home, so s/he contacted a friend who offered to help unload the groceries. It was also “hot” outside so the VA did not want the food to spoil. Shortly thereafter, the VA’s friend unloaded all the VA’s groceries except the milk, which s/he could not locate. The SP eventually was at the VA’s house and the VA asked the SP where the milk was. The SP said, “Well I don’t know, you tell me.” The SP used a “condescending tone” with the VA on this occasion and on other occasions, including at the grocery store. The milk was eventually found in the trunk of the VA’s car and by then, had curdled. · The VA said that the SP placed things on the mobility carts when the SP and VA had shopped another time and the VA wondered if the SP paid for those items at that time. · On an unknown date during a trip to Wal-Mart with the SP, the VA was looking to purchase some absorbent undergarments. The VA was looking at what size to order and the SP said, “Oh, [the size] looks right,” and threw them into the VA’s cart. They were not the right size. The SP was always in a “rush” to get out of the store when they shopped together. · The SP often did not show up for shifts that were agreed upon between VA and the SP, or was hours late, and the SP had a variety of reasons as to why s/he was no longer available to work on given days. · The SP often left shifts earlier than the agreed upon time, left to get him/herself food, asked the VA for food from his/her home, and asked for household materials from the VA. The VA felt “depressed” when the SP would agree to help the VA on a given day and then would not call or show up. The VA put energy into getting things ready for the SP and the VA felt “trapped” between his/her personal belongings being throughout the VA’s house or due to being unable to help him/herself. Facility records show that on June 8, 2026, the SP clocked in at 2:30 p.m. and clocked out at 9:38 p.m., and did not work any other dates during the pay period of May 28, through June 10, 2026. The VA provided information to the CP and P2 that was consistent with what the VA told this investigator. The CP and P2 provided the following information: · The CP stated that the VA told the CP and P2 that the SP called the VA “incompetent” in front of grocery store staff persons when the VA questioned the water purchase. The SP also said that the VA was unable to “advocate” for him/herself. P2 stated that the VA told P2 that the SP “yelled” at the VA for asking questions about the receipt and told the VA, in front of grocery store staff, that the VA “did not know what [s/he] was talking about.” · The CP stated that the VA told the CP that the SP went to a store with the VA at least one other time but was unsure if the SP had left the store without paying for things on other dates. · The CP stated that despite having a TBI, the VA was able to describe things that had happened, in general. The VA was “desperate” for help from anyone including the SP, and there was a lot the VA could not do for him/herself. Being without a staff person negatively impacted the VA, in general. P2 stated that the VA was pretty good at relaying information, that the VA’s brain was still healing from the TBIs, and that the VA used to lose track of time but was doing so less frequently than before. The CM provided the following information: · The CM received information about the report that the SP was “shoplifting” while working with the VA, but did not have any additional information to provide regarding the allegation. · The VA had some memory concerns due to his/her diagnoses and could be sporadic with details, but was “accurate.” P1 provided the following information: · The CP and the VA told P1 that the SP called the VA “incompetent” and “shoplifted” in the presence of the VA. · The SP did not have a set schedule with the VA, and the VA typically asked the SP for help when s/he wanted help from the SP. P1 stated that the VA’s schedule was “maintained directly by [the VA],” and that P1 requested updates from the VA and “monitored service documentation to determine the hours and services actually provided.” P1 also “reviewed service documentation to determine what services were actually completed.” · The SP told P1 via text message that s/he did not put things into the VA’s shopping cart and leave without paying but P1 did not retain the messages with the SP to provide for the investigation. P1 informed the SP on July 7, 2026, that s/he was no longer working for the facility. The SP provided the following information: · On an unknown date, the SP and the VA took the VA’s car to the grocery store. The SP was hungry and got some hot items to eat from the deli counter, paying for those items at the deli counter. At some point during the shopping trip, the SP placed a case of water for him/herself on the VA’s scooter by the VA’s feet because the water would not fit into the basket of the scooter. · During an interivew with this investigator, the SP initially denied knowing if the water was paid for the day of the incident, but then stated that s/he did not pay for the water at the deli and that s/he forgot to pay for the water when they checked out at the front of the store. The SP denied “stealing” the water and denied telling the VA that s/he “never” paid for water. The incident was the only time the SP ever forgot to pay for something while shopping with the VA. The SP hoped that the VA did not pay for the SP’s water. · Once they were at checkout, the SP said that the VA was “upset” with the cashier over discounts on the receipt, and that the SP was at the end of the belt, bagging the VA’s items. The SP stated that while the VA was talking to the cashier, there was a line of shoppers accumulating and that there was “attention” on the SP and VA that the SP did not want. · The VA and the SP began “arguing” about the receipt at the grocery store. The SP said that s/he told the VA, “I am your IHS worker. I am not here to argue with you.” The SP also stated that s/he would not “argue” with the VA because the SP “would not do that.” The SP and VA continued to discuss if the VA’s discount was on the receipt. The SP told the VA, “You don’t need to do this in the store.” The VA responded, “Excuse me, watch who you’re talking to.” The SP told the VA, “I’m not going to do this. It’s time for us to go now.” The SP stated that s/he was “embarrassed” by the “attention” and was “not used to people looking at me like that.” The SP denied calling the VA “incompetent” at the store. Then, they left the store and walked to the VA’s car. Once the VA and SP were in the VA’s car, the SP told the VA that s/he did not like the “deep tone of voice” that the VA used in the store and did not like how the VA was “coming at” the SP. · The VA drove back to his/her house and dropped the SP off at the SP’s car where it was parked near the VA’s house. The SP stated that after the VA dropped the SP at his/her car, s/he took a “short breather” for about five minutes. The SP then went to the VA’s house to unload the groceries and got some of them, but someone else was already helping the VA. The VA was “very upset” and asked the SP where the milk was, but the SP did not know where the milk was. The SP then said the VA and SP agreed to “end it for the day” and would work again the next day so the SP ended his/her shift and left the VA’s house. · The SP denied shopping for his/her own items when s/he was working with the VA in general, but said that the day of the incident, s/he was hungry. All staff persons interviewed for this investigation were trained on the VA’s plans and on the Reporting of Vulnerable Adults Act. Relevant Rules and/or Statutes: Minnesota Statutes 245D.04, subdivision 3, paragraph (a), clause (6), states that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion: The VA and SP stated that on June 8, 2026, the VA and SP went to the grocery store. The SP placed a case of water on the platform of the VA’s mobility scooter near his/her feet. At some point, the VA also placed a carton of milk on the platform of the mobility scooter. The SP stated that s/he was hungry, so s/he went to the deli counter and purchased food there, paying for the food at the deli counter. Then, the SP and the VA went to the checkout and the VA and SP forgot to get the milk and water scanned and left without paying for the items. According to the VA, when the VA told the SP that the SP did not pay for his/her water, the SP said s/he “never” paid for water. The SP denied saying s/he never paid for water and initially denied knowing if the water was paid for but then stated that s/he forgot to pay for the water. The SP stated that the water was the only item the SP ever forgot to pay for while shopping with the VA on this and other occasions. The VA stated that s/he tried to go back into the store to pay for the milk and to get the SP to pay for the water, but the SP said, “Let’s get out of here.” The VA and the SP went back to the VA’s house. When the SP and VA returned from the store, the VA dropped the SP off at the SP’s car near the VA’s house. The SP stated that s/he took a “breather” at his/her car, and the VA asked a friend to help unload his/her groceries because according to the VA, s/he did not know if the SP went home. The SP then went into the VA’s house and finished his/her shift. The CM and P2 each stated that the VA told them that the SP told the VA in front of grocery store staff that the VA was “incompetent” and could not “advocate” for him/herself. The VA stated that the SP spoke to the VA in a “condescending” manner at the store and during other occasions. The SP denied calling the VA “incompetent,” but stated s/he and the VA argued in the store which was inconsistent with the role of a professional caregiver in a facility licensed by the Minnesota Department of Human Services and was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). Although the SP did not pay for a case of water, the VA stated the SP would not let the VA go back and pay for his/her milk and the VA stated the SP called him/her “incompetent,” given that the SP stated taking the water and milk out of the store without paying was not intentional, that there were not details regarding any other occasion the SP took items without paying or “shoplifted” while with the VA, that the SP denied not paying for items other times, and that there was no information that the SP called the VA “incompetent” on other occasions, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. It was not determined whether neglect or emotional abuse occurred (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; 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’s Internal Review stated that policies and procedures were adequate but may not have been followed, but at the time of the Internal Review, the facility could not determine if the SP followed policies. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because the facility took corrective action. On August 25, 2026, the facility was issued a Correction Order for not reporting possible maltreatment to the common entry point within 24 hours.
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