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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: 1097996-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery/Beth Virden Suspected Maltreatment Reported: It was reported that staff persons (SP1 and SP2) did not intervene when a vulnerable adult (VA) ran out of the facility and entered a neighbor’s (N1’s) house causing property destruction. Date of Incident(s): February 10, 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 24, 2026; from documentation at the facility and law enforcement records; and through four interviews conducted with the VA’s guardian (G) who was also the VA’s family member, facility staff persons (SP1 and SP2), and a supervisory staff person (P). The DHS investigator met the VA but did not interview him/her due to his/her limited communication skills. The VA’s support plans, including Behavior Plan, provided the following information: · In December 2025, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included intellectual disability and autism spectrum disorder. The facility provided the VA with two staff during awake hours and one staff during asleep hours. The VA worked best with staff, who were upbeat and calm. The VA responded best to verbal communication but might also need pictures to understand tasks. · The VA liked socializing and interacting with others and staying active in the community. The VA liked playing with his/her iPad, Legos, and toy cars, and hoped to enroll in swimming lessons. · At least one staff person must always have “eyes on” the VA when s/he was not in his/her bedroom or a bathroom. Staff were to regularly and proactively interact with the VA throughout their shift and keep the VA busy. Staff were to maintain the VA’s routine and avoid disruptions, offer choices, remain patient, and avoid power struggles. · The VA was unable to identify dangerous situations or defend him/herself if needed. The VA might engage in behaviors, which had a potential to provoke abuse from others. At the VA’s former residence, s/he had a history of, more than once, leaving the residence without supervision and breaking and entering a neighbor’s house and then aggressing towards the neighbor and/or destroying the neighbor’s property. · If the VA tried to leave the facility without supervision, staff were to redirect or distract him/her to another activity. If staff were unable to locate the VA, they were to immediately look for him/her and if the VA was not located after ten minutes of searching, staff were to call 9-1-1. [Note: The facility records reviewed for this investigation did not provide information specific to the VA’s communication skills; however, consistent information was provided, including by the G, that the VA had limited communication skills and would not be able to tell someone if s/he felt unsafe or needed help.] The facility was a single-family house in a residential neighborhood with other residences next door and close by, including neighbors (N1 and N2). SP1’s incident report provided the following information: [On February 10, 2026, at approximately 4:18 p.m.] Staff and [the VA] were playing in the garage and getting ready to go inside the van when staff noticed [the VA] looking at [N1’s house]. [The VA] suddenly began running toward [N1’s house]. One staff ran next to [the VA] to verbally redirect but was pushed aside, while the second staff followed from near the garage stairs. When they reached [N1’s house], staff observed the front door was unlocked and [the VA] entered without permission. Per policy, staff are not allowed to physically restrain or touch [the VA]. Staff used therapeutic communication and verbal redirection, but [the VA] sat down inside [N1’s house]. [N1’s family member] was inside at the time along with [three children]. [At 4:19 p.m.] One staff called 9-1-1 while the other continued attempting verbal redirection. While on the phone with 9-1-1, the second staff was able to successfully prompt [the VA] to walk out of [N1’s house] … Within about one minute, law enforcement arrived. Law enforcement records provided the following information: · On February 10, 2026, at approximately 4:19 p.m., an unidentified person called 9-1-1 reporting that the VA, who was “non-verbal,” ran out of the facility and entered N1’s house. · Upon arrival, law enforcement officers (LEOs) saw the VA leaving N1’s house with SP1 and SP2. The VA was “visibly upset, yelling, moving erratically, and not following directions … and interacting with [SP1 and SP2].” “[SP1 and SP2] continued trying to calm [the VA] down.” The LEOs approached the VA, who screamed and walked away. More than once, the VA voluntarily sat or lay down on the ground but then would stand and start walking or running away from the LEOs. More than once, the LEOs grabbed the VA’s arm or jacket and more than once the VA tried to punch the LEO. The LEOs determined the VA’s behavior was “violent [and] unpredictable” and placed the VA in handcuffs. An ambulance transported the VA to an emergency room for evaluation. · The LEOs met with neighbors, who had stepped outside during the incident, including N1. “They reported ongoing concerns with [the VA’s] behavior over the past several weeks and expressed fear for their safety and the safety of their children. [N1] stated that this behavior had been ongoing for approximately two months and referenced a prior incident where [the VA] attempted to enter [N1’s] garage and caused damage to a vehicle.” The LEO noted that this incident occurred on December 22, 2025, and that law enforcement officers responded and no further action was taken at the time. [Note: The VA moved into the facility on December 19, 2025. The Department of Human Services did not receive reports of other incidents during that timeframe of the VA leaving the facility without supervision and/or running to a neighbor’s house.] The LEO did not note any property destruction occurring on February 10, 2026. N1 and N2 provided additional information at the outset of the DHS investigation. N1 said that when the VA ran out of the facility and up to N1’s house, an unidentified staff person was “peeking out of the facility and could be heard saying, ‘Don’t go in.’” “[The staff person] did not seem to be in a hurry or even attempt to [approach N1’s house] to further redirect [the VA].” N2 said that after the VA left by ambulance on February 10, 2026, s/he “confronted” an unidentified staff person, who said that N1 should not have left his/her front door unlocked, which N2 believed was a “very inappropriate” response from the staff person. SP1 and SP2 provided the following information: · SP2 said that on February 10, 2026, the VA was in “good spirits” and going about his/her routine that day, which included car rides around the community. SP1, SP2, and the VA were preparing to go for a car ride at the time of the incident. SP1 and the VA were in the garage waiting for SP2. · SP1 said that the VA did not have any restrictions regarding going outside and so while they waited to leave in the van, which was parked in the garage, SP1 opened the garage overhead door and played tag with the VA inside the garage. · SP1 and SP2 each said that at around 4:17 p.m., a food delivery vehicle stopped in front of N1’s house and dropped something off to someone who answered N1’s front door. The VA saw this and “bolted” (ran) towards N1’s house. SP1 ran right next to the VA and SP2 followed a few steps behind “trying to redirect [the VA].” Staff were not allowed to manually restrain the VA. SP1 said that the VA pushed SP1 to the side and kept running. The VA ran up to and opened N1’s front door, which was unlocked, ran inside, and sat on N1’s couch. SP2 followed the VA inside and talked to him/her on the couch while SP1 waited outside as to not overwhelm the VA and at 4:19 p.m., called 9-1-1. The VA was “just sitting there and being calm” despite N1’s family members’ presence. SP2 said that the VA did not show any aggression towards anyone inside the house and did not walk around N1’s house or break anything. SP2 apologized to the people inside the house and eventually told the VA that s/he could drive the van if s/he came outside with SP2. The VA followed without incident, which was around 4:28 p.m. Once they were outside, the LEOs and an ambulance arrived. The facility provided camera footage from their exterior security camera, which showed the incident, on February 10, 2026, as occurring in a manner consistent with SP1’s and SP2’s accounts. The camera showed SP1 running next to the VA and the VA pushing SP1 to the side and running past him/her. The P said that the VA had a history of leaving without supervision at the VA’s previous residence. The VA moved into the facility in December 2025 and had only run from the facility once and did not enter a neighbor’s house during that incident. Staff were trained to verbally redirect the VA and offer options, like going for a van ride. These techniques were sometimes effective and sometimes not. Staff were not allowed to use manual restraints to stop the VA from leaving. During and following the incident, the neighbors were “cursing” and “yelling at” staff and “yelled in” the VA’s face and yet, the VA did not aggress towards anyone. SP1 and/or SP2 were with VA the entire time and were successfully able to redirect him/her out of N1’s house without causing any harm. An ambulance transported the VA to an emergency room, where s/he remained for about two hours and once s/he was “calm,” s/he was discharged back to the facility. The P was not aware of any injury to the VA or destruction to anyone’s property. The G said that s/he did not have overall concerns with the facility staff. The VA seemed to “enjoy” his/her staff and the staff’s “care [was] good.” Facility documentation stated that SP1, SP2, and the P received training on the VA’s support plans, including Behavior Plan, and on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Consistent information was provided that on February 10, 2026, the VA ran into N1’s house and would not immediately leave. Camera footage, SP1, and SP2 provided consistent information that staff ran after the VA and attempted to redirect him/her. The VA pushed SP1 to the side as s/he ran. SP2 followed the VA into N1’s house and spoke with the VA until s/he voluntarily left about ten minutes later. SP1, SP2, and the P each said that staff were not allowed to manually restrain the VA and so SP1’s and SP2’s running after and verbally redirecting was consistent with the VA’s support plans. It was understandable that N1, N2, and other neighbors would be upset about the incident; however, SP1 and SP2 were within “eyes on” supervision of the VA the entire time and immediately followed the VA; the VA did not show signs forewarning that s/he might “bolt” towards N1’s house; and SP1 and SP2 were able to successfully redirect the VA to leave N1’s house without harm to anyone. Therefore, there was not a preponderance of the evidence whether there was a failure to supply the VA with care or services, which were reasonable and necessary to maintain the VA's health and 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed and that there was not a need for additional training or other corrective action. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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