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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: 1125738-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden beth.virden@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left the facility without the knowledge or supervision of a staff person, went to a park, and stabbed a community person. It was also reported that the VA had unsupervised access to the internet when s/he was not supposed to. Date of Incident(s): July 27, 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 17, paragraph (a): 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 August 13, 2025; from documentation at the facility and law enforcement records; and through seven interviews conducted with the VA’s guardian (G), the VA’s case managers (CM1 and CM2), facility staff persons (P1, P2, and P3), and a supervisory staff person (P4). At the time of the investigation, the VA was in jail and represented by an attorney. This investigator spoke with the attorney who was going to then speak to the VA about participating in an interview. However, neither the attorney nor the VA contacted this investigator. The VA’s Master Care Plan stated the following: · In May 2025, the VA moved into the facility seeking support and services relating to his/her diagnoses, which included obsessive compulsive- and antisocial personality-disorder. The facility provided the VA with 24-hour staffing to help with meal preparation, health interventions, and personal cares. · The VA was described as “smart” and “having charisma,” and enjoyed watching movies and listening to music. · The VA had a history of “impulsivity and poor impulse control, particularly under stress, which makes [the VA] a potential risk to others if left unsupervised.” The VA had a history of “past incidents of homicidal ideation.” The facility provided the VA with “continuous supervision [at the facility] and during community outings. Staff maintain ‘eyes-on’ supervision at all times and are trained in de-escalation techniques and trauma-informed care. [The VA’s] interactions with peers and others are monitored closely to help [him/her] navigate social situations safely and appropriately.” [Note: Information obtained during the investigation showed that the VA spent most of his/her time unsupervised in his/her bedroom with staff in the living room outside the room or basement. Given that staff did not maintain “eyes on” supervision of the VA at all times, there was a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), which states, in part, the license holder must provide services in response to the person's identified needs as specified in the coordinated service and support plan and the coordinated service and support plan addendum.] · “[The facility] will provide 12 hours/day of 1:1 staffing with [the VA] ... [The facility] will have 1 staff on at night for [the VA and his/her three housemates].” [Note: An RMS Worksheet provided by CM1 stated that the facility provided 8 hours of shared (1:4) direct care staff per nighttime hours.] · The VA’s rights were restricted in that s/he was not allowed access to cellphones, the internet, and “dangerous items such as, knives/sharps.” · [Note: The VA’s Master Care Plan, Individual Abuse Prevention Plan, Self-Management Assessment, and Support Plan did not provide information about how staff supervised the VA when s/he was in his/her bedroom or about the VA’s history of leaving without telling anyone or without supervision.] The facility was a single-story house in a residential neighborhood. The VA’s and one of his/her housemate’s bedrooms were on the main, ground-level floor. The VA had two windows in his/her bedroom, which faced the side- and back-yards. The basement included two housemates’ bedrooms, a staff office, and a laundry room. There were alarms on the exterior doors, which made a noise when opened. The windows were not alarmed. The surrounding area included several residences, residential streets, trees, and a park about 0.3 miles away, or according to www.bing.com, a six-minute walk. A law enforcement report stated the following: · On July 27, 2025, around 2 a.m., the VA called 9-1-1 stating that s/he “stabbed” a community person (CP) “around 20 times” at the park. Law enforcement officers (LEO) responded to the park and an ambulance transported the CP to an emergency room; “[The CP] was expected to survive.” · The LEO also responded to the facility. The VA told the LEO that s/he “snuck out of [the facility] earlier that evening. [The VA’s] plan was to find someone to kill because [the VA] had thought about doing so for a long time. [The VA] brought [his/her] knife with [him/her] because [s/he] planned to use it to kill someone.” After the incident in the park, the VA went back to the facility, washed his/her hands, and called 9-1-1. [Note: Information was provided by P4 that the VA told the LEO that the VA “snuck out” through his/her bedroom window. At the time of the site visit, this investigator saw the VA’s bedroom window swung open, like a door, and was about three feet by four feet.] · The LEO arrested the VA and charged him/her with murder-1st degree-premeditated. CM1, CM2, and the G provided the following information: · CM1 and the G each said that prior to moving to the facility, the VA spent years in other facilities, “in and out of secure placements … and jails,” “saw therapists,” and was prescribed various medications. The VA had a history of making statements about hurting people. In 2022, the VA stabbed a person in the neck with a fork; the VA had not had any “acts of violence” since. The facility was the VA’s first experience living in a “group home.” · CM2 said, “[The VA] had a long-standing history with mental health issues … [The VA’s] homicidal and suicidal ideations were always present but would fluctuate in severity and level of obsessiveness.” CM2 saw the VA on July 17, 2025, (ten days prior to the incident) and at that time “[the VA] did not report any increase in [his/her] homicidal or suicidal ideations.” · CM1 and the G each said that about a month prior to July 2025, the VA left with a housemate through the front door of the facility without supervision or telling a staff person. After about 30 minutes, the VA and the housemate returned to the house on their own accord. The VA did not have a history of leaving through his/her bedroom window. The G said that the VA ran away from the facility about two to three different times.
· CM1 said that s/he was not aware of specific discussions or instructions regarding whether staff needed to be on the same floor as the VA’s bedroom when the VA was in his/her bedroom or sleeping. CM1 said, “I wasn’t aware they weren’t on the same level … I didn’t know they were spending time in the basement.” · The G said that the VA was not supposed to be alone with other people, including his/her housemates. Staff should be trying to keep the VA engaged. “Ideally, staff would be sitting upstairs in the living room” so they could see and engage with the VA when s/he came out of his/her bedroom. · The G and CM2 each said that there were times they went to the facility around midday and there was one staff person working with the VA and at least one other housemate. A few times, the staff person was in the basement when the G and/or CM2 arrived, and the VA was upstairs. The G and CM1 had concerns about the facility’s provision of the VA’s 12 hours/day of 1:1 staffing. · CM2 said that s/he was part of a discussion with the G, CM1, and P4 about moving the VA’s 12 hours/day of 1:1 staffing to the afternoon/evening, because the VA spent most of his/her time during the day in his/her bedroom and was “more active” at night. There was also discussion about reassigning the nighttime staff’s cleaning duties to the daytime staff so that the nighttime staff was not in the basement for long periods of time cleaning. · CM1 said that the VA typically declined to go on outings with staff and preferred to stay in his/her bedroom. · The G and CM1 each said that the VA was not supposed to have access to knives, but on occasion s/he somehow still got them. At least once when the G and CM1 visited, they saw a PlayStation game console in the VA’s bedroom, which was concerning because the VA was not supposed to have access to the internet. The G and/or CM1 told P4, who immediately removed the PlayStation. P1-P3 and facility documentation provided the following information: · P3 said that s/he worked July 26, 2025, between 7 a.m. and 11 p.m. and saw the VA during that time but did not work directly with the VA. The VA appeared “pretty much good” and stayed in his/her bedroom all day, sleeping. “I didn’t notice anything.” The week prior, P3 worked and said, “[The VA] didn’t show any kind of behavior” and was “doing very well” since moving into the facility in May 2025. P3 did not typically work with the VA and did not know how often staff checked on the VA when the VA was in his/her bedroom. · P1 said that s/he worked July 26, 2025, between 9 a.m. and 11 p.m. and was assigned to work with the VA during that time. The VA spent most of the day in his/her bedroom and P1 checked on him/her every 60-90 minutes, which was how often P1 was trained to check on the VA. P1 said that the VA was “okay” and P1 did not notice anything out of the ordinary. Around 3 p.m., P1 asked if the VA wanted to walk to the park and the VA said, “No,” and stayed in his/her bedroom. Around 8 p.m., the VA came out and asked for something to eat. P1 made him/her dinner and then the VA went back into his/her bedroom. · P1 said that around 10:30 p.m., the VA came out and asked P1 to walk to the park with him/her. However, P1 said, “No,” because it was too late, and P1’s shift ended at 11 p.m. The VA “begged” P1 to walk to the park with him/her and P1 repeatedly declined but P1 told the VA that they could walk to the park the following day. The VA had never “begged” P1 to walk to the park before. The VA was “sad” about not going to the park and sat in the living room for a while and then called his/her family member. P1 asked if the VA wanted to play Uno, and the VA said that s/he needed to think about it. P1 last saw the VA around 10:40 p.m. and at 11 p.m., P1’s shift ended, and s/he left for the day. P1 added that the VA did not have a history of violence at the facility and was typically “calm.” · P2 said that at 11 p.m., s/he arrived at work. The VA was in his/her bedroom and P2 sat in the living room outside the room until about midnight (July 27, 2025). At that time, the VA came out of his/her bedroom and asked for a razor to take a shower and shave. P2 gave the VA the razor and the VA showered without incident. The VA handed the razor back to P2 and said that s/he was going to sleep and went into his/her bedroom around 1 a.m. There was nothing noteworthy about the VA’s demeanor during that time. · P2 said that around 1 a.m., s/he went to the basement to do the laundry, which was one of his/her job duties. P2 first went into the staff office for a period and then to the laundry room. [Note: P2 provided conflicting information to this investigator versus what s/he told P4 immediately following the incident and as recorded in the facility’s incident report.] P2 told this investigator that around 2 a.m., s/he walked upstairs and helped a housemate get cereal in the kitchen. At that time, the VA walked in through the front door from the outside wearing “bloodstained” clothing. P2 asked the VA what s/he was doing outside but the VA did not answer and instead walked straight to the landline phone and called 9-1-1. P2 could not hear what the VA said to the 9-1-1 dispatcher and when the VA hung up the phone, P2 asked him/her, “What did you do?” The VA did not say anything, walked into the bathroom, and washed his/her hands. P2 followed the VA to the bathroom and the VA again did not say anything to P2. The VA walked into his/her bedroom and changed his/her clothes. P2 “immediately” called P4 and while they were on the phone the LEO arrived at the facility. · The facility’s incident report, which was written by P4 and included statements from P2, stated, “At around 2:30 a.m., [P2] reported hearing noises and went upstairs to investigate. [P2] found [the VA] in the living room being interviewed by [the LEO]. [The VA] was handcuffed shortly afterward and escorted to [the LEO’s] vehicle.” [Note: The law enforcement report did not provide information regarding P2’s whereabouts when the LEO arrived at the facility.] · P2 said that s/he did not hear any door alarms when s/he was doing laundry. · P1-P3 were “shocked” and “traumatized” by what happened. P1-P3 provided consistent information that the VA was doing “very well” at the facility and was “quiet” and stayed in his/her room most of the time. P3 said that on July 26, 2025, s/he “didn’t notice anything or hear any complaints from other staff about [the VA] … [The VA] didn’t show any kind of behavior, aggressive behavior.” P1 said that there were “no signs that something was going to happen.” P2 said that on July 27, 2025, the VA said that s/he was going to sleep at 1 a.m., and did not say anything else to P2. P4 and facility documentation provided the following information: · In May 2025, the VA moved into the facility and had restrictions regarding his/her access to cellphones, the internet, and sharps/knives. At that point, all of the facility’s kitchen knives, box cutters, and other sharps were placed in a lockbox in the staff office. P4 showed this investigator the kitchen drawers, which contained only spoons. In addition, all of the facility- or staff-owned electronics with internet-access were accounted for and/or stored in a secure location, this included computers and staff cellphones. All of the bedrooms had built-in TVs on their walls, and after discussion with G and CM1, the VA’s TV was disconnected before s/he moved-in. · At some point prior to July 17, 2025, the VA’s family member gave the VA a PlayStation game console without notifying P4 and staff did not flag the PlayStation as having the capability of internet-access. · On July 17, 2025, the G and CM1 visited the facility and saw the VA’s PlayStation in the VA’s bedroom, and alerted P4 of its potential for internet-access. P4 removed the PlayStation and secured it in the staff office but also added that without a TV, the VA was not able to use the PlayStation, including for internet access. There was no information the VA ever hooked up his/her PlayStation to a different TV in the facility. · On July 25, 2025, CM1 emailed P4 stating that s/he believed the VA was somehow accessing the internet. P4 believed the VA might be accessing the internet through his/her housemates’ cellphones. Although the VA was restricted from internet-access, the VA’s housemates did not have restrictions to the internet, and each owned a cellphone with internet-access. Prior to CM1’s email on July 25, 2025, P4 had no information the VA might be accessing the internet; this was the first s/he heard of the concern. · Later that same day, July 25, 2025, P4 tested his/her suspicions, of the VA using his/her housemates’ cellphones, by turning off the Wi-Fi (internet) at the facility for a period to determine what was happening. The VA “became very upset” about the Wi-Fi not working but when P4 asked why the VA was concerned about the Wi-Fi, the VA did not respond. The VA’s housemates did not ask about or seem concerned about the Wi-Fi. P4 left the Wi-Fi turned off for the time being. · On July 26, 2025, between 1 and 5 p.m., P4 worked with the VA to setup his/her goals and create a calendar to hang outside the VA’s bedroom door. The VA seemed “relaxed” and “okay” during that time, and “not upset” about the Wi-Fi. · Between 8 and 9 p.m., P4 received more than one call from P1 relating to the VA. The VA was “upset” about the facility’s Wi-Fi connection and wanted to talk to P4. P4 asked the VA why s/he was concerned about his/her housemates’ internet and the VA said, “Sure. You’re right. Never mind,” and the call ended without incident. P1 called back shortly after stating that the VA wanted his/her PlayStation. P4 talked to the VA and suggested s/he spend time with staff since the VA had been in his/her bedroom most of the day; the VA agreed, and the call ended. P1 called again stating that the VA wanted to walk to the park with P1 but P4 said that it was “too late” at night. P4 believed the VA was “upset” about P1 not walking to the park with him/her. · P4 said that the VA preferred to spend time in his/her bedroom. There was a staff assigned to him/her during the daytime and the staff was responsible for getting the VA invested in the community, which included outings and walks. When the VA was in his/her bedroom, staff checked on him/her “regularly” but there was no specific time interval for these checks and staff were not required to stay on the same floor as the VA. · P4 did not recall any conversations with the G, CM1, or CM2 regarding a requirement for staff to remain on the same floor as the VA. The VA’s assigned 1:1 staff was “generally stationed” on the same floor, but they might also go to the basement if needed. The staff computer and client medications were in the basement. · During the night, there was one staff person watching all of the housemates and so they might be upstairs or downstairs. The exterior doors had alarms and so staff were expected to respond to the door if they heard an alarm. P4 later learned from the LEO that the VA left the facility on July 27, 2025, by going through his/her bedroom window, which did not have an alarm. The housemates, including the VA, did not have any history of leaving through a window. · Since moving in, the VA left the facility twice without telling anyone. One time, the VA was standing outside with a housemate and the two walked away but returned 30 minutes later without incident. Another time in the middle of the night, the VA walked out the front door which alarmed and alerted staff who responded immediately. P4 said that following the VA leaving during the night, s/he met with the G, CM1, and/or CM2 to discuss the VA’s staffing. P4 believed the VA might have left during the night because s/he was taking advantage of there only be one staff person during that time. P4 said, “I don’t recall the team requesting an adjustment to increase night staffing.” Instead, P4 understood that they were going to monitor whether the VA had a pattern of leaving during the night and if that continued to occur, they would determine the best approach to address it. The second time the VA left during the night was the incident on July 27, 2025. · The VA was “very friendly” and “never showed signs of aggression” since moving into the facility. P4 saw the VA “getting upset … only one time” and it was “not very, very upset.” This happened the time when the VA left the facility with a housemate. The housemate was allowed to be unsupervised in the community, but the VA was not. When the VA and the housemate returned and P4 redirected the VA about leaving, the VA “raised [his/her] voice” but then said, “Okay, okay, okay,” and the incident ended. · One time at the facility, date unknown, P4 saw a “spit out” pill on a plate in the VA’s bedroom and believed the VA “spat out” his/her medication that day. P4 asked the VA about it and the VA said that s/he was aware s/he should not do that and that P4 “would report that.” P4 was not aware of the VA missing or spitting out medications at any other points. · Staff “searched” the VA’s bedroom “daily.” Twice, staff found a knife in the VA’s bedroom, but it was not a facility-owned knife. A facility incident report stated that on May 25, 2025, “during a routine cleaning and room search,” staff found a red knife inside a hat in the VA’s closet. Staff reminded the VA that s/he was not allowed to have knives. The VA told staff that s/he did not know where the knife came from and then apologized and said it would not happen again. Staff gave the knife to the G. P4 instructed staff to always monitor the VA during store outings. “The team continued to discuss reinforcing the practice of conducting random room searches to ensure safety and compliance with individual restrictions.” · A facility incident report stated that on June 29, 2025, “during a routine room search and cleaning,” staff found a black knife under the VA’s bed. The VA told staff that s/he got the knife during his/her first week at the facility when s/he left with a housemate into the community. P4 suspected this was not true given that staff searched the VA’s bedroom daily and the knife had not been seen previously. Staff reminded the VA that s/he was not allowed to have knives. The VA apologized and stated that it would not happen again and that s/he did not intend to harm anyone but liked having knives because they looked “cool.” Staff took the knife and secured it in a safe location. “The team continued to discuss reinforcing the practice of conducting random room searches to ensure safety and compliance with individual restrictions.” · P4 suspected the VA’s housemates, who were allowed unsupervised time in the community, gave the red and/or black knife to the VA but P4 had “no concrete proof” this was occurring. More than once, P4 spoke with the housemates and they “consistently denied bringing [the VA] anything.” In addition, staff searched the housemates’ belongings after community outings and “we did not find any prohibited items.” · P4 said that regarding the VA’s knife on July 27, 2025, information was provided to P4 by the LEO that the VA went to a gas station before going to the park and P4 wondered if the VA might have bought the knife at the gas station. However, the VA did not have access to money. Staff bought the VA treats and snacks here and there using facility funds. One time, the VA’s family member gave the VA $20 cash, but other than this incident, P4 was not aware of times the VA had access to money. · Regarding what happened on July 27, 2025, P4 said, “It’s something that wouldn’t have crossed my mind that this would happen” with the VA. Facility documentation stated that P1-P4 received training on the VA’s Master Care Plan and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported that on July 27, 2025, at some point between 1 and 2 a.m., the VA left the facility through his/her bedroom window without the knowledge or supervision of a staff person, went to the park, and stabbed the CP with a knife. The VA then returned to the facility and called 9-1-1. An ambulance transported the CP to the emergency room where s/he was expected to survive. The LEO arrested and charged the VA. Consistent information was provided by the G, CM1, and CM2 that the VA had a history of homicidal ideations but that the VA’s last “act of violence” was in 2022. P1-P4 said that the VA had no violent or aggressive incidents since moving into the facility. On July 17, 2025, CM2 saw the VA and said that the VA did not report any increase in his/her homicidal ideations at that time. On July 26 and 27, 2025, P1-P4 worked with the VA and said the VA was “fine,” “relaxed,” and “not upset.” The VA spent time in his/her bedroom, which was typical behavior, ate dinner, showered, and at 1 a.m., July 27, 2025, the VA told P2 that s/he was going to sleep. P3 said that s/he “didn’t notice anything or hear any complaints from other staff about [the VA] … [The VA] didn’t show any kind of behavior, aggressive behavior.” P1 said that there were “no signs that something was going to happen.” Although the VA was restricted from having knives, on May 25 and June 29, 2025, staff found a knife hidden in the VA’s bedroom. P4 suspected the VA’s housemates gave him/her the knives; however, s/he had “no concrete proof” of this. P4 asked the housemates about it, and they denied doing so, and staff searched the housemates’ belongings when they came home from outings, but no prohibited items were found. The VA did not reveal where s/he got the knives. Regarding the VA’s access to the internet, P4 first heard of this concern on July 25, 2025, and later that same day, turned off the facility’s Wi-Fi, which based on the VA’s reaction, seemed to indicate s/he was accessing the internet in some manner using the facility’s Wi-Fi. P4 left the Wi-Fi turned off. The VA’s support plans stated that the facility provided the VA with “eyes on” supervision and 12 hours of 1:1 staffing per day. Although it was determined this level of supervision did not always occur, which was a licensing violation as stated above, the incident on July 27, 2025, occurred at night when the facility provided the VA with eight hours of 1:4 staffing. Although CM2 stated there was discussion about moving the VA’s 1:1 staffing to the evening, this was not documented anywhere and P4 said that this was a discussion that included monitoring the VA’s behaviors at night to see if adjustments were needed; the monitoring was ongoing at the time of the incident. In addition, there was no information staff were required to remain on the same floor as the VA while s/he was in his/her bedroom. Although the G and CM1 believed staff were remaining on the same floor, they also both acknowledged that the VA spent time in his/her bedroom with staff in the living room, and as such it was unknown if moving the VA’s 1:1 staffing to the evening would have changed the outcome given that the VA could have still left through his/her bedroom window without staff knowing. Although there was no set time interval for staff to check on the VA during the night, P2 saw the VA at 11 p.m., and 12, 1, and 2 a.m., and did not see the VA leave, hear any door alarms, or notice anything noteworthy about the VA’s demeanor during that time. P2 was completing his/her work tasks and believed the VA was asleep in his/her bedroom. The VA did not have a history of leaving the facility through his/her bedroom window. While there remained concern about how the VA accessed knives and staff supervision, given that the care and services provided to the VA at the time of the incident were consistent with the VA’s support plans and with the information available to the staff, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services that were reasonable and necessary. 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).
Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The incident was not similar to past incidents involving staff or the VA at the facility. Following the incident, the facility installed alarms on all bedroom windows and implemented safety checks on “high-risk” housemates during the night. “All high-risk clients will be reassessed to determine whether their current placement remains appropriate.” Action Taken by Department of Human Services, Office of Inspector General: On November 10, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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