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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: 1070490-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy Minnesota Department of Human Services 651-431-3444 Suspected Maltreatment Reported: Allegation one: It was reported that a vulnerable adult (VA) left the facility without the knowledge of two staff persons (SP1 and SP2) and was found in two community person’s (CP1’s and CP2’s) home. Allegation two: It was also reported that on a second occasion, the VA left the facility without the knowledge of two staff persons (SP3 and SP4) and was found in CP1’s and CP2’s driveway. Date of Incident(s): March 17 and 19, 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 April 3, 2026; from documentation at the facility and law enforcement records; and through fifteen interviews conducted with a facility supervisory staff person (P1), a staff person (P2), SP1, SP2, SP3, SP4, CP1, CP2, the VA, the VA’s four guardians (G1, G2, G3, and G4) who were also the VA’s family members, and two additional family members (FM1 and FM2). The VA enjoyed swimming, roller skating, playing basketball, listening to music, going shopping, watching television, and spending time with his/her family members. The VA also enjoyed sitting outside. The VA’s diagnoses included mild intellectual disabilities, obsessive-compulsive disorder, depression, and Parkinsonism. The VA attended a day program one day a week. The VA’s Individual Abuse Prevention Plan stated that the VA was very trusting and social and might not identify when s/he was in a dangerous situation. The VA had a lack of community orientation skills and might walk onto strangers’ property. The VA had no unsupervised time at home or in the community. The VA’s Self-Management Assessment of Risks stated that the VA might not take reasonable precautions with strangers. The VA might not dress suitably for weather conditions. The staff persons provided 24-hour awake supervision of the VA. The VA had a history of leaving the facility without the knowledge or supervision of staff person. Alarms were on the facility’s doors. The VA also had a history of sitting in the middle of the street and sometimes took money or valuables from others. The VA’s Support Plan from the county stated under “Rate Inputs: Direct Care staffing: Average Staff Ratio 1:1.” However, the only additional information in the VA’s plans regarding 1:1 supervision for the VA was related to the day program. The VA’s Elopement Procedure stated that if the VA left the facility without supervision, the staff persons were to follow the VA if they saw him/her leave or to search the facility and grounds for the VA. If the staff persons did not find the VA, they were to call the main office and other nearby facilities operated by the license holder and ask for assistance in searching for the VA. If a supervisory staff person told the staff persons to call 9-1-1, the staff persons were to call 9-1-1 and provide information about the VA and his/her leaving from the facility. The staff persons were also required to fill out an incident report. The facility was located in a rural area and was accessed by a long-curved driveway from a paved road that ran along the front of the property. The speed limit on the road was 45 miles per hour (MPH). Directly across the road from the facility was a private home (CP1’s and CP’s) at the end of another long driveway. A tall wooden fence enclosed the main door to the facility and a large section of the front yard. There was no gate allowing access out of the fenced-in area. A second entry door opened into the attached garage, which had an overhead door in the front as well as a side door. An alarm on the door to the garage sounded when the door was opened. There was no direct access to the backyard from the main level of the facility. There was a door on the lower level giving access to the back yard, but the door was located in a locked staff office. The VA stated that s/he loved the facility’s staff persons but did not provide information about the incidents. Facility documentation showed that SP1, SP2, SP3, SP4, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Allegation one: It was reported that the VA left the facility without the knowledge of SP1 and SP2 and was found in CP1’s and CP2’s home. CP1 and CP2 provided the following information: · On March 17, 2026, CP1 was in his/her home when s/he found the VA “going through the refrigerator.” CP1 called 9-1-1 and placed the VA in his/her car so that the VA did not have to walk back to the facility without shoes or a coat. CP1 then drove his/her car to the street and parked. CP1 did not know how long the VA was in his/her home before CP1 found the VA in the kitchen, but after s/he called 9-1-1, the VA sat in CP1’s car for approximately 15 to 20 minutes before a staff person walked out of the facility and came to CP1’s car. At approximately the same time, a law enforcement officer (LEO1) arrived and CP1 and LEO1 took the VA back to the facility. · CP2 stated that during the last four years, the VA had a history of leaving the facility and entering the home of CP1 and CP2. On a previous occasion, the VA hit CP2 in the face. After the VA hit CP2, CP2’s child was afraid the VA might hit him/her. The VA told CP2 that s/he went to CP2’s home because s/he believed it was a “camp.” In the past, the VA had also entered another neighbor’s home. Three or four years prior, CP1 and CP2 met with the facility’s license holder and a representative from the city to discuss the continued problem of the VA leaving the facility unsupervised. A fence was built at the front of the facility, but CP2 stated that the VA could still get out of the facility through the garage. The VA also went outside to the fenced area and “screeched at the top of [his/her] lungs” for “hours.” · CP2 stated that the staff persons typically did not talk to CP1 or CP2 when they tried to get the VA to return to the facility. CP1 stated that the VA “never” wore shoes when s/he walked to CP1’s and CP2’s home, no matter what the weather was like. CP1 estimated that their driveway and the facility’s driveway were each approximately 500 feet long. The VA walked very slowly and CP1 believed it would take the VA between 15 and 30 minutes to walk from the facility to CP1’s home. SP1 provided the following information: · On March 17, 2026, at 1 p.m., SP1 began his/her work shift and at 2 p.m., SP2 began his/her work shift. At that time, the VA was the only client at the facility. SP1 stated that the VA was “obsessing” about which staff persons were scheduled to work and was verbally aggressive to SP1 and SP2. SP1 and SP2 were both in the kitchen, but SP1 “peeked out every so often to check on” the VA, who was sitting in the living room. At approximately 2:15 p.m., the VA told SP1 and SP2 that s/he was going to his/her bedroom. SP1 then went to the lower level of the facility to do laundry and SP2 worked on dinner preparations. After approximately seven minutes, SP1 returned to the main level of the facility, where it was “weirdly quiet” so SP1 looked for the VA. SP1 checked the facility and then looked outside and saw a police car at the end of the driveway. SP1 went outside and walked to the police car and told LEO1 that s/he was sorry the VA left the facility unsupervised and they “should have been paying more attention.” LEO1 had the VA in his/her police car and drove the VA to the facility where SP1 assisted the VA back into the facility. SP1 believed that the VA went to CP1’s and CP2’s home because s/he would do so to take soda from them. SP1 believed the VA was unsupervised for approximately 10 to 20 minutes, but was in the police car for some of that time. · Although there was an alarm on the door to the garage, on the day of the incident, the alarm did not go off. SP1 stated that some of the staff persons occasionally unplugged the door alarm because the clients would be “curious” about who was entering the facility. The overnight staff persons sometimes unplugged the door alarm so that the alarm did not wake the clients. SP1 stated that s/he never unplugged the door alarm. In the past, SP1 found the door alarm unplugged on three occasions. At those times, SP1 plugged the door alarm in. SP1 stated that the VA required 1:1 staffing and the staff persons “switched off” watching the VA during each work shift. · The staff persons were not assigned as the VA’s 1:1 staff person, but rather “had to choose among each other.” The staff persons “will switch off hanging out with” the VA during their work shifts. SP2 provided the following information: · When SP2 arrived at the facility for his/her work shift, s/he went to the kitchen and began preparing dinner and then went to the bathroom on the lower level. During this time, the VA was sitting on the couch in the living room and SP1 was in the kitchen talking on his/her cell phone about his/her work schedule. Approximately two minutes later, SP2 returned to the main level and did not see the VA in the living room. The VA’s bedroom door was open and because his/her television was, SP2 believed the VA was in his/her bedroom so SP2 went to the kitchen and continued preparing dinner. SP2 was unable to see the garage door from where s/he worked in the kitchen. Approximately five minutes later, approximately 2:17 p.m., SP1 said that it was quiet and asked where the VA was. SP1 checked the VA’s bedroom and then looked outside and saw a police car at the end of the driveway. SP1 telephoned P1 and walked down the driveway to where the VA was sitting in the police car. SP2 also saw the police car but remained inside because the other clients were scheduled to return to the facility a short time later. · SP1 and the VA returned to the facility and SP1 told SP2 that the VA entered CP1’s home and asked for a soda and CP1 telephoned LEO1. SP1 completed an incident report. SP2 did not believe that the door alarm sounded when the VA went outside, but the alarm worked earlier and later in the day. SP2 believed that s/he might not have shut the door “all the way,” which would stop the alarm from sounding if the door was opened again. The overnight staff persons sometimes turned off the door alarm so that it would not wake the clients too early in the morning. SP2 never turned off the door alarm. · SP2 believed it would take five minutes for the VA to walk to the neighbor’s home, but it might have taken the VA seven minutes that day because s/he spent some time in his/her bedroom before leaving the facility. The VA did not have the “stability” to run quickly. · SP2 stated that the VA typically “told on” him/herself and told the staff persons when s/he was going to leave the facility, so the staff persons had time to block the door or to be prepared to follow the VA, but on that day the VA did not tell the staff persons s/he was leaving. When the VA told the staff persons s/he was going to his/her bedroom, s/he usually went to his/her bedroom. The VA became upset and had behaviors if the staff persons “constantly looked at [him/her]” or checked on him/her too frequently. · The VA usually “picked” which staff person would be his/her 1:1 staff person and would frequently “switch” to another staff person throughout the day. P1 provided the following information: · The VA had a history of leaving the facility without supervision. On March 17, 2026, at 2:15 p.m., SP1 called P1, and said that the VA went to his/her bedroom to watch television while SP1 was making dinner and SP2 was doing laundry and a short time later, when they checked on the VA, s/he was not in his/her bedroom. P1 said to search the facility for the VA and then check outside. SP1 told P1 that s/he saw a police car at the end of the driveway and P1 told SP1 to go outside and talk to LEO1. The VA was in the police car wearing a tee shirt, pants, and socks, but was not wearing a jacket or shoes. The staff persons told P1 that the door alarm did not sound when the VA left the facility. P1 stated that after the incident the door alarm was broken and was replaced. The VA did not sustain any injury during the incident. · The VA had a 1:1 staff person who was trained to be within sight or sound of the VA at all times. If the VA was in his/her bedroom, the staff persons were to regularly check on the VA. If the VA left the facility, the staff persons were to follow him/her and attempt to redirect him/her to return to the facility. If they were unable to redirect the VA, the staff persons were trained to stand between the VA and the road and continue to talk to the VA about returning to the facility. The staff persons could also call P1 and have him/her talk to the VA about returning to the facility. The VA was hard to redirect when s/he decided s/he wanted to leave. The garage door was the only door that the VA could use to leave the facility unsupervised. The VA attempted to leave the facility unsupervised “several times a week.” P2 stated that at times there were not two staff persons working at the facility even though the VA required 1:1 staffing and the other clients were present. At those times the staff persons called P1 to tell them there was only one staff present. The staff persons had to watch the VA closely so that s/he did not “sneak” out of the facility. The staff persons did not need to remain in the same room as the VA, but needed to know where s/he was. The VA could be in his/her bedroom unsupervised. At the time of the incident on March 17, 2026, P1 was not at the facility because s/he went to pick up the other clients and returned to the facility after the VA was returned. G1 stated believed that there was security on the facility’s door, but that it was “evidently not good enough” to keep the VA from leaving the facility unsupervised. The VA did not like anyone telling him/her “no” and also did not like anyone “following [him/her] around.” After the incidents, the VA called G1 and told him/her about what occurred. G2 and FM1 stated that for years they were “very” concerned that the VA was able to keep leaving the facility unsupervised. The facility fenced the front yard, but the VA was able to leave through the attached garage. The VA was “sneaky” and would “slide out the door” if the staff persons were not looking. The staff persons told G2 and FM1 that they could not lock the garage door because of safety reasons. Neither had other concerns about the care the VA received at the facility. G4 stated that the VA had “taken off” from the facility for years, but the staff persons were unable to lock the doors to keep the VA from leaving. The facility contacted them when the VA left the facility unsupervised. FM2 stated that s/he was concerned about the VA’s safety because the facility was located in a rural area and the VA would talk to anyone s/he met or get in their car. In the past, the VA walked into neighbors’ homes and hit community persons and staff persons. The VA was very strong and could be violent when s/he became angry. The VA recently hit a LEO when s/he took the VA back to the facility. FM2 believed the facility had alarms on the doors, but they could not lock the doors. G3 stated that s/he had no concerns about the care the VA received at the facility, but believed that it was hard for the facility to hire staff persons. LEO1’s Incident Report dated March 17, 2026, stated that at 2:13 p.m., CP1 called 9-1-1 and at approximately 2:23 p.m., LEO1 arrived at CP1’s home. CP1 told LEO1 that s/he found the VA in his/her kitchen. A facility staff person told LEO1 that the facility’s garage door was left open and the alarm on the garage door was not operational. In addition, only two staff persons were working at the time and one had to remain inside the facility. At 2:37 p.m., LEO1 left the facility. According to Weather Underground weather history for Scandia, MN, on March 17, 2026, at 2 p.m., it was 17 degrees Fahrenheit. On March 19, 2026, at 3:35 p.m., it was 52 degrees. Conclusion for allegation one: A. Maltreatment: On the afternoon of March 17, 2026, SP1 and SP2 worked at the facility. At that time, the VA was the only client at the facility and information was consistent that the VA required 1:1 supervision. At approximately 2:15 p.m., the VA told SP1 and SP2 that s/he was going to his/her bedroom. SP2 went to the kitchen to begin dinner preparations. Inconsistent information was provided as to whether SP1 went to the lower level of the facility to do laundry or remained in the kitchen talking on his/her cell phone. At some point, the VA left the facility without the knowledge of the staff persons. The VA did not wear a coat or shoes when s/he left. Although it was likely that the door alarm did not go off and alert the staff persons to the VA leaving the facility, the failure of the door alarm did not mitigate the need for SP1 and SP2 to provide supervision to the VA. CP1 stated that s/he was in his/her home when s/he found the VA “going through the refrigerator.” CP1 called 9-1-1 and moved the VA to his/her car at the end of the driveway.
LEO1’s Incident Report dated March 17, 2026, stated that CP1 reported the incident at 2:13 p.m. and LEO1 arrived at CP1’s home at approximately 2:23 p.m. At some point, SP1 told SP2 that it was “quiet” and checked the VA’s bedroom, but was unable to find the VA. SP1 then looked outside and saw a police car at the end of the driveway. SP1 telephoned P1 and walked down the driveway to where the VA was sitting in the police car. CP1 and LEO1 took the VA back to the facility. Although the VA did not sustain an injury during the incident, given that the VA was able to walk down a long driveway, cross a road, walk down the neighbor’s driveway and enter the neighbor’s house; that SP1 and SP2 did not know the VA left the facility and was gone for over ten minutes even though s/he was the only client at the facility; and that SP1 did not find the VA until after LEO1 arrived at the facility, there was a preponderance of the evidence that there was a failure to supply the VA with care or services that were reasonable and necessary to 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. Facility documentation showed that SP1 and SP2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Although not outlined in the VA’s plans, information was consistent that the VA had 1:1 supervision. Given that SP1 and SP2 each stated that they were aware that the VA required 1:1 supervision and that staff persons “switched” off who was with the VA and that at the time of the incident SP1 and SP2 had no other clients at the facility to supervise, SP1 and SP2 were each responsible for the supervision of the VA. In addition, regardless of whether the alarm sounded when the VA left, having an alarm on a door does not mitigate SP1’s or SP2’s responsibility to ensure the supervision of the VA. SP1 and SP2 were 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 SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the VA did not sustain any injury during the incident. Allegation two: It was also reported that on a second occasion, the VA left the facility without the knowledge of SP3 and SP4 and was found in CP1’s and CP2’s driveway. CP2 stated that on March 19, 2026, CP2 was outside and saw the VA walking down the driveway to CP2’s home. CP2 told the VA to go home and the VA yelled, “No.” A staff person then walked out of the facility holding a Swiffer broom, which s/he used to keep a barrier between him/her and the VA. CP2 told the staff person s/he needed to take the VA back to the facility, but when they remained on CP2’s driveway. CP2 then called 9-1-1 and a law enforcement officer (LEO2) arrived and LEO2 and the staff person took the VA back to the facility. SP3 stated that on March 19, 2026, SP3 and SP4 worked at the facility with three clients. SP4 had recently begun working at the facility and was still “in training.” At approximately 3:20 p.m., SP3 was in the kitchen preparing dinner, SP4 was doing laundry on the lower level of the facility, and the VA was sitting in the living room when SP3 heard the garage door alarm sound. SP3 believed the VA went outside so s/he called for SP4, who “instantly” came upstairs and went outside after the VA. SP3 stated that s/he did not see the VA leave because of where s/he was standing in the kitchen and could not follow the VA because s/he had to provide supervision for the other two clients. SP4 stated that the VA frequently tried to leave the facility without supervision. On the day of the incident, SP4 was working in the kitchen with SP3 when the door alarm sounded. SP4 did not see the VA go out the door but immediately went outside and saw the VA on the road in front of the facility. SP4 talked to the VA about returning to the facility but the VA did not want to return. SP4 called P1, who also talked to the VA about returning to the facility. During this time, the VA went onto CP2’s driveway where CP2 was and who called 9-1-1. SP4 and the VA waited in CP2’s driveway until law enforcement arrived and assisted SP4 with directing the VA back to the facility. P1 stated that on March 19, 2026, at approximately 1:15 p.m., the VA left the facility immediately followed by a staff person who was able to redirect the VA back to the facility. At approximately 2:15 p.m., the VA again left and walked to CP1’s and CP2’s driveway, where CP2 “confronted” the VA. SP4 heard the door alarm and followed the VA out of the facility and attempted to redirect the VA to the facility. SP4 called P1 as s/he was redirecting the VA. The VA did not sustain any injury during the incident. LEO2’s Incident Report dated March 19, 2026, stated that when LEO2 arrived at CP1’s home at approximately 3:25 p.m., s/he walked back to the facility with the VA. According to Weather Underground weather history for Scandia, MN, on March 19, 2026, at 3:35 p.m., it was 52 degrees. Conclusion for allegation two: Information obtained showed that twice on March 19, 2026, the VA left the facility and each time was immediately followed by a staff person. The second time, the VA went to CP1’s and CP2’s driveway, where CP2 called 9-1-1. SP3 and SP4 provided consistent information that each heard the door alarm and that SP4 immediately followed the VA out of the facility. Although the VA left the facility, given that staff persons immediately followed the VA and attempted to redirect the VA back to the facility, there was a preponderance of the evidence that there was not a failure to supply the VA with reasonable and necessary care or services including supervision. It was determined neglect did not occur (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 two internal reviews and determined that the facility’s policies were adequate and were followed by the staff persons. After the incidents, the staff persons were retrained on the facility’s policies and the alarm system failure was addressed. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal.
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