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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: 1102830-AFC (Adult Foster Care) 1107649-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a vulnerable adult (VA) was locked inside the facility while a staff person was not at the facility. The VA experienced a medical emergency and contacted 9-1-1, however emergency services were unable to enter the facility until law enforcement (LE) broke a facility door. Date of Incident(s): November 1, 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 attempted to be obtained during an unannounced site visit conducted on November 25, 2025. However, the SP and the VA were not at the facility at that time, and did not respond to a phone call made by this investigator. This investigator left a voicemail requesting a return call which the SP responded to via phone days later. The SP and VA were ill, unable to meet in-person, and phone interviews were arranged thereafter. Additional information for this investigation was obtained remotely, including documentation from the facility, and law enforcement records; and through four interviews conducted with the VA, a facility supervisor (P), the VA’s case manager (CM), and the SP. Collaborative Living Options was licensed to provide Home and Community-Based Services (HCBS) as a contracted provider at the facility, and Schneider Ronald Joseph Adult Foster Care (AFC) was a licensed adult foster care facility. The SP was a direct support staff person under both licenses and lived at the facility. The P provided program coordination and management of the HCBS license held by Collaborative Living Options. The VA lived at the facility and received care and supportive services such as protection, supervision, household services, and living-skills assistance. The services were individualized and based on the needs of the VA, as identified in the support plan. Throughout this report, “facility” refers to the adult foster care facility and the services provided therein. Facility documentation showed the VA enjoyed communicating with friends and family on the phone. The VA spent time watching “old movies and TV shows,” shopping, and riding around the community in a golf cart. The VA was diagnosed with developmental disabilities, anxiety, depression, and multiple physical health issues. The VA’s Coordinated Service and Support Plan (CSSP) Addendum showed the VA had three hours of unsupervised time within the facility. The VA was aware of the location of the emergency contact list and where to go if there was an emergency. On November 1, 2025, around 11:30 a.m., the VA called a medical triage line due to left chest pain, and stated s/he was scared to die. The VA stated s/he was unable to get out of the facility as the doors were locked, and the VA did not have the keys. The VA also stated the SP “locks it every time [s/he] leaves and it is for [the VA’s] safety." LE records provided the following information · LE responded to the facility on November 1, 2025, at 11:36 a.m., as the VA was having chest pains, and was unable to exit the facility. LE found a “log chain” with padlock on a gate around the fence surrounding the facility so LE scaled the fence to enter the facility yard. LE found a padlock on an entry door to the facility and heard a person “pounding on a window,” and observed the VA waving “frantically” from a window. · LE was unable to enter the facility due to a padlock on a screen door, as well as the entry door being locked from the inside. LE broke the screen door, and entry door in order to enter the facility. Thereafter, Emergency Medical Services (EMS) was able to enter the facility and assessed the VA. · The SP was contacted, and the VA and SP could be heard yelling at each other. The SP did not believe the VA needed to go with EMS, and the SP said s/he would bring the VA to the hospital. However, EMS completed an assessment, and the SP had yet to arrive back to the facility. The VA was taken to the hospital by EMS, and the SP did not arrive to the hospital for approximately 45 minutes. · The SP told LE the SP locked the house with the padlock, and it was a “slip of memory.” LE noted the SP did not seem to understand the “concern or severity” of the incident. The SP said s/he was at a property about 20 miles away, the SP stated s/he had the right to be gone from the facility with the VA remaining at the facility for up to three hours. The SP added the VA had “all the keys,” however, the VA denied having any keys. · While at the hospital the VA stated, “It’s okay,” at the facility. · LE did not complete any further criminal investigation. Medical Records showed the VA was seen at a medical facility on November 1, 2025, due to the feeling of a “dripping sensation” in his/her chest. While at the medical facility the VA informed medical personnel the dripping sensation had been resolved, and no longer had a health complaint. Medical personnel completed an evaluation and noted the VA seemed likely to have had a “manifestation of [his/her] hallucinations which have been previously evaluated.” The VA was diagnosed with atypical chest pain, and no further treatment was provided. It was noted the VA had previously had similar concerns, and was encouraged to follow-up with his/her mental health provider, however the VA was reluctant in completing the mental health appointment. The VA provided the following information: · The VA said s/he contacted a medical triage line due to a feeling that s/he did not know “where my heart was.” The VA added that s/he had a spasm in his/her chest, but his/her mental health then caused her additional issues. The VA said s/he could have left the facility by using the front door, or a window if needed, but s/he got flustered and scared. · The VA repeatedly stated how s/he enjoyed living at the facility, and explained how the SP treated the VA well. · The VA stated that s/he had access to facility keys, and was aware the SP had left the facility. Additionally, the VA said s/he had a cell phone, and was able to contact the SP at any time. · The VA was aware s/he had unsupervised time, and had not had any similar issues as that of the incident on November 1, 2025. The VA said his/her health returned to normal after the incident. The SP provided the following information: · The SP said s/he “accidently” used a padlock on the backdoor, but the VA would have been able to leave the facility via the front door. The SP believed the VA’s mental health caused the issue to escalate and the VA was unable to problem solve during the incident. · The SP said s/he would typically use a padlock to lock the backdoor when s/he and the VA left the facility together. · The SP said the VA had unsupervised time, and was able to contact the SP via phone call if needed. · The SP was not aware of any health concerns with the VA prior to leaving the facility on November 1, 2025.
The CM provided the following information: · The CM said the VA enjoyed living at the facility. The CM was at the facility in August 2025, and there was not a padlock on the door. The CM also said prior to the incident s/he had not received any concerning reports of VA being left unsupervised. · The CM said the VA was an accurate reporter of information. The P said the VA should not have been locked inside the facility using a padlock. The P said s/he did not have any concerns with the care and services the SP had provided prior to the alleged incident. The P and the SP were each trained on the VA’s plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Conclusion: On November 1, 2025, the VA contacted a medical triage phone line due to a medical emergency. LE arrived at the facility and was unable to access the VA as the facility had a padlock on an entry door. The SP was not present, and the VA was unable to open an entry door. LE was able to enter the facility after breaking the door/lock. The VA was assessed by EMS and later evaluated at a medical facility. Medical records showed the VA’s symptoms resolved while at the medical facility, but medical personnel completed an evaluation. The VA was diagnosed with atypical chest pain, and no further treatment was provided. The VA’s health returned to normal, and s/he did not have any on-going issues related to the medical emergency. Client specific documentation showed the VA had three hours of unsupervised time at the facility. The SP said on November 1, 2025, s/he left the facility, and “accidently” used a padlock on an entry door. The SP used the padlock on occasions when both the SP and the VA left the facility. The SP said the VA could have left the facility by using the front door of the facility, which the VA also acknowledged within his/her interview. The VA told LE that s/he did not have keys to the doors but the VA and the SP each told this investigator that the VA did have keys. Although there was a padlock on the entry door, the VA had the ability to leave the facility using a different entry door or window. Furthermore, the VA stated his/her mental health caused the issue to escalate as s/he was unable to problem solve while experiencing the medical emergency. Given that the VA had three hours of unsupervised time at the facility, that the VA had a cell phone to contact the SP, that the VA had keys to the doors and had exit options, and that the VA was not harmed, there was not a preponderance of the evidence whether the SP failed to provide the VA with reasonable and necessary care and services. 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, but not followed. The reporting of incident policy was not followed because the VA’s team was not informed of the incident promptly. There were no prior similar allegations. The SP was retrained regarding reporting incidents and trained to ensure all doors were accessible in case of emergencies. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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