MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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:

1069747-H_CRS (Home and Community-Based Services-Community Residential Setting)
1069743-HCBS (Home and Community-Based Services)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6572

Suspected Maltreatment Reported:

It was reported that a staff person (SP) was sleeping instead of providing the required 1:1 awake supervision to a vulnerable adult (VA). The VA left the facility unclothed without the SP’s knowledge and subsequently passed away in the community due to the weather conditions.

Date of Incident(s): January 27, 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 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 February 9, 2026; from documentation at the facility and law enforcement records; and through six interviews conducted with the VA’s guardian (G) who was also the VA’s family member, the VA’s case manager (CM), and facility supervisory staff persons (P1, P2, P3, and P4). Additional staff persons (the SP, P5, P6, and P7) provided information to law enforcement and that information was included in this report. Attempts were made by telephone and mail to contact and interview the SP, but the SP did not respond by the completion of this investigation.

The VA’s support plans, including Support Plan Addendum, and obituary provided the following information:

· In July 2025, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included bipolar disorder.

· The VA enjoyed dancing, going out to eat, and visiting his/her family, including the G. “[The VA] brought joy, laughter, and a gentle kindness to everyone who knew [him/her].” The VA had an “infectious belly laugh – one that could fill a room and make everyone smile.”

· The facility was to provide the VA with a 24/7 1:1 staff person. [Note: Consistent information was provided by the G, the CM, and P1-P4 that the VA’s 1:1 staff person was to stay awake, including during the night. P4 said that all facility clients were automatically supplied with an awake 1:1 staff person, at a minimum, regardless of if this was documented in their specific plans. Some clients might require more than one staff person.]

· The facility was to provide the VA with crisis respite services, which included assistance with assessing situations and determining factors causing the VA’s crises; supervising the VA to ensure his/her health and welfare; and developing and implementing support plans to increase the VA’s stability and successfully intervene with crises when necessary.

· The VA was susceptible to abuse from others and lacked the skills necessary to understand abuse and defend him/herself. The VA had “zero hours” of unsupervised time at the facility and in the community. Staff were to always be on the premises when the VA was at the facility but might not always be in the same room as the VA. Staff were to stay within visual range of the VA when in the community.

· If staff discovered the VA was no longer on the facility’s premises or within visual range in the community, they searched the immediate area for ten minutes and if they were unable to locate the VA, they called the G. If the VA was not located after 15 minutes of searching, staff were to call 9-1-1.

The facility was a single-family, split-level house. Upon entering, there was a landing with stairs leading up or down. The VA’s bedroom, a living room, and a bathroom were downstairs. There was also another client bedroom downstairs, which was not being used as of January 27, 2026, but contained an unmade bed and other furniture in preparation for the next client. A hallway stretched the length of the basement and led from the VA’s bedroom, past the spare client bedroom, through the living room, and down a short hallway to a door leading into the attached garage. Upstairs there was a bathroom, a living room, a kitchen, and a dining room, and two client bedrooms, which were in use on January 27, 2026, and who were being supervised by two staff persons (P5 and P6).

A law enforcement report provided the following information:

· On January 27, 2026, at approximately 4:24 a.m., law enforcement officers (LEO) were driving when they saw a person lying naked and not moving on the side of a residential road. The LEO called paramedics, who responded and declared the person dead at 4:31 a.m. The person was cold to the touch with slight lividity. The person was not carrying any identification. [Note: According to historical weather data, the outdoor conditions on January 27, 2026, between 3 and 5 a.m., included a temperature range of 5 to 7 degrees Fahrenheit (˚F) with average wind speeds of 18 to 28 miles per hour. Around 4 a.m., the “feels like” temperature, which is calculated by including wind speeds and humidity, was around -10 ˚F.]

· The LEOs canvassed the immediate area to determine the person’s identity. The facility was approximately 0.6 miles (or approximately seven city blocks) from the location where the person was discovered. Upon arriving at the facility, the LEO saw the garage swing door, on the front of the house, ajar. The LEO knocked on the main front door and P5 answered. P5 and P6 had been sitting in the upstairs living room all night with two clients asleep in the upstairs bedrooms. P5 told the LEO that no clients were missing from the facility but then P5 walked downstairs to where the SP was working with the VA. P5 immediately saw the VA’s bedroom door ajar and that the VA was not inside his/her bedroom or present anywhere in the basement. P6 followed P5 and discovered the SP asleep inside the empty client bedroom. The SP was lying on the client bed, covered with blankets, and the lights were turned off. P6 had to wake up the SP to get his/her attention. The SP did not know the VA was missing.

· The LEO determined the VA left through the garage swing door, which was accessible from the basement level. The VA most likely walked out of his/her bedroom, through the basement living room, past the client room where the SP was sleeping, and out the door into the attached garage. There were bare footprints in the snow outside of the garage. P5 and P6 told the LEO that they would have noticed if the VA left through the front door and they did not see this. P5 said that the SP was responsible for supervising the VA and should have been in the basement living room and should have seen the VA walk through on his/her way out.

· P5 and P6 each told the LEO that they did not see the VA on January 26 or 27 and never went into the basement prior to the LEO arriving. P5 said that s/he saw the SP briefly around 10 p.m. on January 26, as the SP arrived at worked and walked straight downstairs.

· A neighbor’s doorbell camera, which was approximately 0.3 miles from the facility, showed the VA walking past the camera at approximately 3:22 a.m., heading in the direction where s/he was later discovered.

· The SP told the LEO that s/he went into the spare client bedroom to sleep and brought blankets with him/her from home for this purpose. The SP did not know what time s/he went into the spare bedroom and did not see the VA or know the VA was missing until s/he was woken up by P6 on January 27. The SP told the LEO that s/he knew s/he should not be sleeping at work.

· The LEO interviewed the staff person (P7) who worked with the VA on January 26, 2026, between 2 and 10 p.m., prior to the SP’s arrival. P7 said that there was “nothing out of the ordinary.” The VA took his/her medications, ate, and went to bed without incident and then the SP arrived and P7 left.

· The LEO arrested the SP and charged him/her with criminal neglect of the VA. The charges remained pending at the completion of the DHS investigation.

The G provided the following information:

· In 2025, the VA moved into the facility after being discharged from a hospital. Over the years, the VA was in and out of hospitals and residential facilities for mental health symptoms or other reasons. The facility was to provide crisis respite services to the VA, which meant one awake staff person 24/7. The VA could be in his/her bedroom without a staff person in the same room. However, the G assumed staff were checking on him/her in his/her bedroom, especially if they heard the VA up at night, and even more so when the VA was experiencing a manic phase as was the case on January 27, 2026.

· The G explained that every six to eight weeks, the VA experienced untriggered manic phases, which included being “very energetic” and not sleeping. The VA was “rarely aggressive.” Around the end of January 2026, the VA “was due for” a manic cycle and had been “struggling” the week leading up to January 27. More than once that week, the VA walked out of his/her bedroom unclothed; however, staff were always present and when they told the VA to put his/her clothes back on or go back into his/her bedroom, the VA always did so. If the VA approached an exterior door, staff would tell him/her to step away from the door and the VA always did so.

· On February 9 or 10, 2026, family members packed up the VA’s belongings in his/her bedroom, which had not been touched since the VA was last there on January 27. At that time, family members noticed the VA had arranged his/her toys in a half circle on his/her bed. The G explained that the VA might sleep with one or two toys at night but not all of them. The conduct of bringing all his/her toys to bed and arranging them in a specific order indicated to the G that the VA’s “mind was fractured” that night (January 26 into 27) and s/he was “really manic.”

· The G explained further that on January 14, 2026, about two weeks prior to the VA’s death, the VA attended an appointment with a urologist because s/he was experiencing increasing incontinence at night. The G provided a copy of the appointment records, in which the urologist wrote, “[The VA] would benefit from waking one time at night to urinate as [s/he] goes to bed at 7 p.m. and wakes at 6 a.m. [The doctor] would recommend alarm or waking at 12 or 1 a.m. to urinate to see if this resolves the enuresis.”

· After the appointment, the G gave the urology appointment records to the facility’s “P.M. staff” and talked to P1 and P2 about the need to wake up the VA at night. This was verbally discussed at the VA’s biweekly interdisciplinary team (IDT) meetings, which included P1, P2, and/or P3, the G, and the CM. The G did not document these discussions. P1 or P2 told the G that they would talk to staff and create a chart where staff would check-off (mark a checkbox) that they woke the VA up each night. The G did not know if this chart was ever created. The G routinely asked the VA if anyone woke him/her up that night and only one time, the VA said, “Yes;” every other time, the VA said, “No.”

· On January 26, 2026, at 4:05 p.m., about 12 hours prior to discovery of the VA’s death, the G texted P1 and P2, “If you could also remind staff to wake [the VA] at night to go to the bathroom.” The G provided a screenshot of this text message, which showed that there was no response from P1 or P2 to the G’s text.

· The G believed that had the SP woken the VA up to use the restroom around midnight or 1 a.m. on January 27 as required, the SP would have likely noticed the VA was awake and struggling and prevented the VA from leaving.

· There were no cameras or door alarms at the facility, but the G had no concerns about this because there was always supposed to be a 1:1 staff person present and awake “right outside [the VA’s] bedroom.” “Someone would always have eyes on [the VA]. Someone would always be there to keep [the VA] safe. In this instance (on January 27, 2026) that did not happen.” The G added that the facility “did” provide care and supervision for the VA, and they “did well” managing his/her previous manic cycles. However, “in the end” the SP was not there when s/he needed to be to stop the VA from leaving.

The CM provided the following information:

· The VA did not have a history of wandering outside in the middle of the night and if the SP had been awake and present and told the VA to return to his/her bedroom, the VA would have done so. The VA’s death was “so sad,” “unbelievable,” and “didn’t make sense.”

· The CM did not recall discussing the implementation of nightly bed checks when setting up the VA’s services at the facility. The CM assumed that because the facility provided crisis respite services, they would automatically be providing some sort of nightly bed checks.

P1-P4 provided the following information:

· P1-P4 each said that the VA was talkative, smart, and “very sweet.” The VA needed assistance every day to remain safe. The facility provided a 1:1 awake staff person for the VA, 24 hours a day/night. The VA could be in his/her bedroom without a staff person, but the staff person needed to stay in the basement (same level as the VA’s bedroom). The staff person was not required to physically check on the VA during the night when the VA was inside his/her bedroom. The VA had no history of self-harming or leaving through a window.

· P3 said that the staff person typically sat on the couch in the living room outside of the VA’s bedroom. There was a bathroom in the basement, and the staff person was supposed to tell the upstairs staff if s/he needed to use the bathroom but P3 did not know if staff always communicated this. There was a spare client bedroom in the basement, but the staff person was not to go into that bedroom unless they were cleaning or preparing for a client to move in, which was not the case on January 26 or 27, 2026. The staff person was not allowed to hang out or lie on the client bed in the spare client bedroom.

· P3 and P4 each said that the upstairs staff and/or downstairs staff were not required to check on one another throughout the night. The upstairs staff were responsible for the upstairs clients, who might get up to smoke during the night, and did not have reason to go into the basement during their shifts.

· P1-P4 each said that leading up to January 27, 2026, the VA was experiencing a manic phase, which included having delusional or nonsensical speech, staying up at night, and undressing and/or trying to leave the facility. P1 said that a few days prior to January 27, the VA had undressed and/or tried to leave two or three times during one shift. This was recorded in the VA’s daily notes. P3 said that the VA’s manic phases typically lasted a couple of weeks.

· P4 said that the VA might walk towards an exterior door, undressed, but s/he was “always redirectable.” The VA never planned to leave but rather it appeared “impulsive” and part of the VA’s manic episodes. P4 said that the VA’s increasing manic symptoms leading up to January 27 were documented in daily notes and the SP was required to read the daily notes and might have also been made aware of the VA’s symptoms when talking with other staff at shift change. The facility did not have a way to verify if the SP read the daily notes or what was discussed at each shift change.

· P1, P2, and P3 each said that they had biweekly meetings with the VA’s interdisciplinary team (IDT), which included the G and the CM. In January 2026, the VA had been experiencing increasing nighttime incontinence and the G “requested” staff wake up the VA each night and prompt him/her to use the restroom. P1 and P3 each said that the G requested staff wake up the VA around midnight or 1 a.m., but P2 said that it was 10 p.m. at shift change. P4 was not part of these meetings.

· P1 said that s/he did not see the VA’s urology appointment records but said that the records would have been given to P3. P3 said that s/he never saw the VA’s urology appointment records and that s/he was not aware that the request to be woken up each night was ordered by a doctor. P2 said that the request had come from the G, not a doctor.

· P1, P2, and P3 each said that there was a process prior to implementing such a thing as waking up the VA each night. P1 believed that there needed to be approval from the VA’s team and that P3 needed to draft a rights restriction before implementation. P3 said that they were in the “first stages of brainstorming.” P2 said that s/he requested the task be added to the VA’s needs checklist but was not sure if that happened. P1 and P2 each said that they believed some staff were waking up the VA each night but that it was not officially added to the VA’s charting as of January 27.

· P1 said that the G sometimes texted him/her to remind staff to wake up the VA each night and when P1 received these texts, s/he relayed the message to staff.

· P3 and P4 each said that there was no prior concern or information the SP slept at work, and they had no prior related concerns with the SP’s conduct.

· P4 said that the facility had a doorbell camera, but it did not record or log activity.

The facility’s daily notes for January 20 through 27, 2026, included the following:

Facility documentation stated that the SP received training on the VA’s support plans, including Support Plan Addendum, and on the Reporting of Maltreatment of Vulnerable Adults Act.

In addition, in the SP’s training records, the facility’s untitled memorandum, dated February 5, 2025, stated the following:

All [crisis respite programs operated by the license holder] are awake overnights. This means at no point during the day, afternoon, evening, or middle of the night should there be any staff sleeping, appearing to be asleep, or resting horizontally. This also means no employees should bring aides to facilitate sleeping, including blankets, pillows, cots, etc.

The SP signed that s/he acknowledged reading this memorandum on February 18, 2025.

Relevant Minnesota Statutes and Rules:

Minnesota Statutes section 245D.05, subdivision 1, paragraph (b), states in part that if the responsibility for meeting the person’s health service needs has been assigned to the licensed holder in the support plan or the support plan addendum, the licensed holder must maintain documentation on how the person’s health needs will be met, including a description of the procedures the license holder will follow.

Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071.

Conclusion:

A. Maltreatment:

On January 27, 2026, at some point prior to 3:22 a.m., the VA left the facility, unclothed, and walked approximately 0.6 miles away where s/he collapsed and died. The outdoor temperature was below freezing. The VA was discovered by the LEO approximately one hour later. The LEO went to the facility where they saw the garage swing door ajar and bare footprints in the snow outside the garage. P6 had to wake the SP up to get his/her attention and let him/her know the VA was gone. The SP was sleeping in the spare, client bedroom in the basement just down the hallway from the VA’s bedroom. The VA would have walked past the spare bedroom and through the living room to access the attached garage before leaving.

P1-P4 each said that the SP was responsible for the VA’s care and supervision and should not have been sleeping. The SP told the LEO that s/he knew s/he was not supposed to be sleeping. The failure to provide 24/7 awake supervision was in violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a).

The facility’s handling of the VA’s urology records and the urologist’s documentation to wake the VA up each night around 12 to 1 a.m. was not implemented after 12 days of receipt, which was both concerning and inconsistent with the standards of professional caregivers in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes section 245D.05, subdivision 1, paragraph (b). However, given that the VA most likely left about 3 a.m. after which time staff should have woken the VA up, it was not determined whether waking the VA up would have changed the outcome or whether the VA would have left anyhow.

However, the VA required an awake 1:1 staff person 24/7 and the SP was sleeping in a client bedroom when the VA walked through the living room to get to the attached garage, which was where the SP should have been present and awake. The SP’s decision to bring blankets into work with him/her, go into the spare client bedroom, turn off the lights, and fall asleep allowed the VA to leave unnoticed. The SP’s conduct of sleeping when s/he was required to remain awake was not accidental or therapeutic conduct. Therefore, there was a preponderance of the evidence that there was a failure to supply the VA with care or services, which were reasonable and necessary to obtain or maintain the VA’s physical or mental health or safety.

It was determined that 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).

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.

The SP was responsible for the VA’s care and supervision and told the LEO that s/he was supposed to stay awake and signed a facility memorandum acknowledging such. The SP received training on the VA’s support plans, including Support Plan Addendum, and on the Reporting of Maltreatment of Vulnerable Adults Act.

The SP was responsible for 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 neglect for which the SP was responsible was not recurring because it was a single incident. However, it was “serious” maltreatment because it resulted in the VA’s death.

The SP was disqualified from providing direct contact services.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. The facility installed alarms on the exterior doors and retrained staff on expectations regarding sleeping at work. The facility also created a protocol to verify whether staff were staying awake during the night.

Action Taken by Department of Human Services, Office of Inspector General:

The SP 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 the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.

On March 17, 2026, the facility was issued a Correction Order for the violation outlined in this report.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/