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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: 1110720-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that when a vulnerable adult (VA) began receiving services at the facility (October 22, 2025), the VA was not provided access to his/her mail and/or packages that were delivered to the facility which contained the VA’s medications, including insulin and anti-depressants, for at least two weeks. In addition, the VA never received services and was issued a notice of service termination by the facility effective January 26, 2026. During the course of the investigation, it was reported that at some point between January 5 and 28, 2026, the VA resumed services with the facility and although the VA was to be provided with daily supports and services totaling 28 hours each week, staffing was only available to the VA about two days each week until mid-February. During this time, it was also reported that the staff person (P9) who worked with the VA brought his/her children to work on occasion. Alleged Licensing Violation: It was reported that the facility provided the VA with transitional services when the VA moved into the facility’s ICS setting. According to Minnesota Statutes and the Federal Waiver Plan, transitional services must occur from a provider who does not have direct or indirect financial interest in the property and therefore, the VA was not to receive transitional services from the facility. Date of Incident(s): Ongoing between October 22, 2025, and March 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 December 3, 2025; from documentation at the facility; and through eight interviews conducted with the VA, the VA’s case manager (CM), the VA’s medical healthcare provider (MHP), a property manager (PM) of the apartment building in which the facility was located, a facility staff person (P9), and three administrative staff persons (P1-P3). However, P3 only confirmed his/her ownership and administrative position within the company and declined to provide information for this report and referred this investigator to information provided by P1. Additionally, subsequent phone calls were made to P2 to obtain additional information but P2 did not respond by the completion of this investigation. Attempts were also made via telephone to contact and interview an additional supervisory staff person (P4), but the attempts were not successful. The VA lived by him/herself in an apartment, referred to as the facility throughout the report, that shared a building with 121 other apartments. The license holder leased three apartments and provided services to residents in the three apartments who subleased their respective apartment from the license holder. [Note: The license holder provided the VA with integrated community supports (ICS). The VA’s apartment and the other two apartments each were “provider-controlled” ICS settings. An ICS setting was a setting in which a provider had an approved setting capacity report and had direct/indirect control over a person’s living unit (e.g., apartment), which meant that the provider either owned, operated, or leased the living unit, or had direct or indirect financial interest in the property or housing, including a financial relationship with the property owner. A person who lived in an ICS setting was not required to receive ICS. However, when a person lived in an ICS setting, ICS could only be delivered by the provider who controlled the setting.] The VA’s diagnosis included asymptomatic human immunodeficiency virus, latent tuberculosis, type II diabetes (insulin dependent), heart disease, cerebral infarction (stroke), anxiety disorder, depressive disorder, post-traumatic stress disorder, prefrontal lobe dementia, hypertension, obstructive sleep apnea, and insomnia. The VA also had unspecified vision loss/blindness and used a cane, assistive technology, and a service animal/dog to complete activities of daily living. The VA enjoyed spending time with his/her family members, outdoor activities, and going on walks with his/her service dog. The VA was not subject to guardianship. At the onset of this investigation in November 2025, the facility did not provide a client file as requested so the CM provided the VA’s plan information. [Note: This was a violation of Minnesota Statutes, section 245A.04, subdivision 5, paragraph (a), clause (2), which states in part when the commissioner is exercising the powers of this chapter, and section 626.557 the commissioner must be given access to documents and records, including records maintained in electronic format.] In January 2026, the facility stated they began providing the VA with ICS services. P1 provided information that the VA began receiving ICS services on January 28, 2026, however, information from the VA, P9 and timecards showed that the VA’s ICS services began on January 7, 2026. The facility then provided the VA’s plans/file which were dated January 28, 2026. Regarding services from October 2025 to January 2026: The facility did not maintain a client file for the VA that contained documentation relating to the VA’s admission including a legally enforceable lease agreement, client rights information, evidence of informed choices; and the VA’s care/service needs including plans and assessments identifying areas and level of support needed, risks, objectives, and person-centered planning. [Note: This was a violation of Minnesota Statutes, section 245D.095, subdivision 3, which states in part that the license holder must maintain a record of current services provided to each person served.] P1 provided information that this was because the VA moved into the ICS setting but was not yet receiving ICS services. P2 also provided information that the VA had not yet received services but stated that the facility had documentation of “[the VA’s] Support Plan and everything we created after seeing [the VA’s] MNCHOICES Assessment and speaking to [him/her] as well.” The VA’s MnCHOICES Assessment and Supplemental Checklist updated in July 2025; the VA’s RMS Worksheet-Integrated Community Supports and Companion Document completed by P1 on October 6, 2025; the VA’s Support Plan updated by the CM and the VA on October 22, 2025, and signed by P1 on October 28, 2025, provided the following information: · The VA was able to “advocate” for him/herself and use his/her “own judgement” to “navigate and interact” with others and within “most” situations. However, the VA had “almost a complete” loss of vision that occurred within the past year so the VA was not able to “independently” complete tasks/activities of daily living within the home and community that s/he was previously capable of and had to “learn” “new” skills and “adjust” to “new” ways of doing things which included assistance from others. This caused the VA to “sometimes” “struggle” with being “overwhelmed,” “frustrated,” “quick to anger,” withdrawing from others, not wanting to leave his/her apartment, and having “a lot of anxiety, especially when [s/he] had to go somewhere [alone] due to not being able to see.” · The VA used assistive technology on his/her phone which then projected/displayed onto the VA’s TV so that the VA was able to independently manage his/her finances, check his/her emails, and communicate with others. However, the VA required assistance when completing paperwork. · The VA’s health was “closely” monitored by a care team of medical health professionals and “specialists” who prescribed the VA with daily/weekly medications that were automatically refilled and mailed to the VA’s residence, including medications that had to be refrigerated within 12 hours of delivery. The VA was able to independently self-administer his/her medications but needed assistance in “setting up” some of the medications that were prescribed in pill-form and had a similar size or “feel” that the VA was unable to differentiate by touch. Additionally, the VA checked his/her blood pressure daily and the information was then entered into the VA’s MyChart account for the VA’s care team to review/monitor. · The VA lived independently but with limitations on his/her abilities to complete daily living/community activities due to the VA’s loss of vision and other health conditions. Therefore, the VA received ICS services from the facility consisting of four hours of in-person services and 1:1 staffing, seven days a week. According to the VA’s Support Plan and RMS Worksheet, the VA was to begin ICS services on October 15, 2025, but this “service start date” was later updated to October 22, 2025. Additionally, the facility was to provide the VA with daily staff support to help the VA maintain his/her independence while staff persons assisted the VA with transportation, community integration and navigation, health and household management, meal preparation, and developing adaptive skills within a new home and community environment. Staff persons also were to provide the VA with daily “encouragement” and “coaching” to help the VA “problem solve,” “build confidence and self-sufficiency,” and “practice new skills and self-advocacy” that would allow the VA to remain “safe, stable, and well.” · According to the VA’s Companion Document, the VA’s vision loss and “reduced” independence resulted in the VA having increased “stress and anxiety” and a need for “consistent oversight” from staff persons to maintain the VA’s health/safety. Staff persons were to help the VA maintain a “clean” and “organized” living environment and help the VA manage his/her “regular health routines” which were “easily disrupted” without staff support and “reminders.” Additionally, the VA was not able to “safely” and “independently cross busy streets, navigate stores, or manage public spaces” on his/her own and therefore, accessing the community without staff assistance would place the VA in “danger” and such situations caused the VA “significant stress and fear of harm.” Staff persons were to provide the VA “guidance for safe movement” within his/her home and in the community and the VA was to receive daily access to the community which included transportation and staff assistance to complete “errands like grocery shopping.” Emails and text messages between the VA, the CM, P1, P2, a supervisory staff person (P4), the license holder’s main email address, and/or other county staff persons included the following information: · On September 30, 2025, the CM emailed the license holder’s main email address for general information relating to the living arrangements, expenses, and placement availability for the VA to receive services at the facility’s ICS setting. Shortly thereafter, P4 responded to the CM and then communicated with both the CM and the VA the following day to schedule a tour of the facility. · On October 2, 2025, around 12 p.m., the VA met with P1 for an in-person tour. At this time, the VA told P1 that s/he liked the facility and was “interested in moving forward” with his/her placement into the facility’s ICS setting with services. Later that afternoon, the VA text P1 asking about the “next steps” and a “general timeframe” of when s/he would be able to move into the apartment. P1 responded and told the VA to “plan on getting out of the [VA’s current] apartment by” October 15, 2025, and that P1 would contact the CM to “get the process rolling.” · On October 3, 2025, the CM and P1 communicated via email about the VA moving into and receiving services from the facility. The CM provided P1 with copies of the VA’s MnCHOICES Assessment and Supplemental Checklist. Additionally, P1 completed the VA’s RMS Worksheet and emailed a copy of the document to the CM for review and approval. P1 also told the CM that s/he “assured” the VA that P1 would “prepare the unit” and “arrange for a direct support professional to assist [the VA] during the move.” · The VA was initially scheduled to move into the facility on October 15, 2025, but this was delayed and rescheduled to October 22, 2025, because the CM was not able to find a transitional service to help the VA move within this timeframe at a financial “cost” that reflected the VA’s funds/budget allotted for this service. Despite the delayed move-in date, text messages between the VA and P1 showed that P1 agreed to meet the VA and the VA’s family member (FM) at a business complex specified by P1 around 9:30 a.m. on October 17, 2025, to provide the VA with a key fob to the facility so that the VA and the FM could start moving “some” of the VA’s belongings into the apartment that weekend. During that morning while the FM was driving the VA to the business complex, the VA sent a text message to P1 with an updated estimated time of arrival being 9:15 a.m. However, P1 replied via text message that s/he was “sorry” and “misplaced” the key fob but requested another key from the PM and asked the VA to “reschedule this to Monday (October 20, 2025).” At approximately 3 p.m. on October 21, 2025, the VA then arrived at the facility’s apartment complex to meet with the PM and obtain the key fob needed to enter the facility. On the morning/afternoon of October 22, 2025, the VA moved into the facility. (See Alleged Licensing Violation below.) · On October 23, 2025, the VA talked to the PM about obtaining a key to his/her mailbox and the PM told the VA that s/he could get the VA a copy of the key if needed, but the VA first had to talk to P1. The VA then text P1 requesting a key to the VA’s mailbox and P1 responded to the VA that s/he would “check [the] office” and “hoped” that administrative staff persons did not “misplace” the key. · On October 27, 2025, the VA emailed P1 and the CM asking about what “next steps” were needed to get a key to his/her mailbox and accessing his/her packages. P1 responded that administrative staff persons could not find the mailbox key and that P1 would contact the PM to make new key to give to the VA. The VA also told P1 that the post office was not able to fully process his/her change of address request until the VA had “proof” of living at the facility and asked if P1 or the PM could help the VA with this. The VA also asked for any documentation that an apartment building’s management team provided to tenants at “move-in” and any information about the building’s rules or amenities. · On October 30, 2025, the VA emailed P1 requesting an update on obtaining a key to his/her mailbox. The VA had confirmed with his/her healthcare provider that the VA’s medications had been filled and delivered to the VA at the facility’s address. Additionally, the VA received various community and county services and supports that required a “proof of residency” from the VA so the VA requested P1’s assistance for completing a lease agreement so the VA could provide it for the community and county services. Later that morning, the VA text P1 requesting an update about obtaining the key but P1 did not respond. The VA then called the CM who also attempted to contact P1 but P1 also did not respond to the CM. · An email dated October 31, 2025, from the VA to P1 stated: I understand that you may not think my mail key is important, it is to me. I receive all of my medication and tremendous amounts of communication by USPS. I need to be able to access my mail. I think 10 days is a fair amount of time to wait. […] Lastly you had told me your partner was finding a person to assist me with getting places and getting things done. Can I have the people your partner is considering so I can at least call them to get an idea if they can work out? We had chatted and the latest I would be talking to people or meeting people to talk with was the end of this week. · Also on October 31, 2025, the CM called and left a voicemail for P1 about the VA’s concerns as mentioned in his/her email and requested a call back, but P1 did not respond. · On November 3, 2025, (12 days after the VA moved in) P1 text the VA “apologizing” and stating that s/he had been on a medical leave but would respond to the VA’s and the CM’s questions/concerns later that afternoon. However, P1 did not do so. · On November 4, 2025, the VA text P1 asking P1 to call him/her. The CM also emailed P1 about maintaining adequate communication with the VA and his/her care team, asking when staffing would become available to the VA, and about ongoing concerns that resulted from the VA not receiving the support and services s/he needed and that were required by the VA’s care plans including access to his/her mail that contained the VA’s medications. P1 did not respond to either the VA or the CM. · On November 5, 2025, at 11:16 a.m., P1 emailed the CM and the VA and “apologized for the delay” in response. P1 then said that s/he emailed the PM requesting that the VA be provided a key to his/her mailbox. P1 also stated: I informed [the VA] before we started the process that it could take some time to hire a direct support professional, and [s/he] stated to me [s/he] could be patient, but it was necessary to get moving out of [his/her] place fast. Since this was a rush move, with none of the usual time and resources allotted to assist us, things can break down. […] Right now, we have interviews set up with Direct Support Professionals next week for [the VA] and we will advise when we have some candidates we think can work. As always, we will run it by [the VA] before hiring someone for [him/her]. · At 12:42 p.m., the VA “thanked” P1 for responding and said that s/he would “check in with the [the PM] shortly to get that key.” Shortly after, the CM also responded that s/he was “happy to hear” that the PM was contacted so that the VA could get his/her mail key and asked for updates regarding the additional items/concerns that were communicated to P1. However, P1 did not respond to the CM. · On November 6, 2025, at 7:58 a.m., the VA emailed P1 stating: Please respond to this email by 10 a.m. I am requesting […] a meeting ASAP […] in person or by phone. I feel like this move has been a train wreck from the beginning. [The VA and the CM] received an email with promises yesterday. Exactly one was followed through on. I have a mail key and was able to take my meds that I have missed for 7 days. Nothing else happened. The state has listed out a set of rules for these moves. They also have ICS requirements. I am extremely grateful to be here. That said, I am completely willing to be packed up and be moved to an acceptable unit if this is no longer feasible. I have reached out to you several times with no resolution to these issues (I do have keys). I have been moved and completely left alone. If I do not have a meeting set up by noon and everything completed as promised by 4 p.m., I will be in a position that I absolutely have to take further action, by asking the ombudsman to step in and come up with an acceptable resolution. Being placated with emails promising things and then are not done is no longer acceptable. […] I've been reasonable. […] I have physical handicaps, not functional. · At 9:58 a.m., P1 responded and scheduled a phone call with the VA and the CM for 2 p.m. that afternoon. Shortly thereafter, after asking an unknown person in the apartment building for help, the VA “realized” that his/her medications were not in his/her mailbox. The VA then text P1 asking how to access his/her packages that had been mailed to the facility. P1 told the VA to contact P2 for this information and the VA did so. However, P2 did not respond. Later that afternoon at 1:37 p.m., P1 emailed the VA and the CM with concerns that the VA made “threats” about the PM and the licensed holder which P1 said was a “pattern” of “abusive” behavior by the VA and would not be “tolerated.” P1 also said that s/he would update the VA and the CM by the end of the day regarding a decision on whether the facility would “continue to retain [the VA] as a client in [the facility’s] program.” · At 2:15 p.m., the CM responded via email stating: I am extremely concerned and frustrated by the situation […] regarding [the VA’s] care and services. Based on my understanding and direct interactions, [the VA] has expressed thoughts and feelings that stem from legitimate frustration about services that were promised but not received. As a client, [s/he] is entitled to communicate [his/her] concerns regarding unmet commitments that significantly affect [his/her] daily functioning and overall well-being. Since [his/her] move-in on October 22, 2025, [the VA] has repeatedly been left without proper staffing, without access to [his/her] mailbox which directly impacts the receipt of prescribed medications, and without the ICS services that were promised. These failures are not minor oversights; they represent a clear lack of support and disregard for agreed-upon care plans. Due to inadequate follow-through, [the VA] has been placed in vulnerable situations, including going without medication, being expected to independently navigate a new community despite having no eyesight, and experiencing considerable strain on [his/her] everyday life. When [the VA] and I have attempted to reach out for assistance, there has been little to no response. As an ICS program providing 24-hour services, it is required that an alternate contact number be made available when a manager is out. Unfortunately, this procedure was not followed. Your message alleging “threatening behavior” is deeply troubling, as it disregards the very real and serious concerns this client has been raising regarding the quality and safety of the services provided. The frustration [the VA] has expressed stems directly from the pattern of neglect and failure to meet program obligations, not from any intent to threaten anyone. […] · On November 7, 2025, the VA emailed P1 asking P1 to “forward” emails regarding packages of the VA’s medications that were delivered to the apartment complex’s mail/package room. Shortly after this, P1 responded with an access code for the mail/package room. The CM then emailed P1 that the code s/he provided to the VA did not work and the VA needed “immediate access” to his/her medications to maintain the VA’s health/safety. P2 then contacted the VA and provided an updated code that allowed the VA to access the mail/package room and his/her packages of medications. · Later that day, P1 emailed the CM and “sincerely apologized” for the “frustration, disruption, and distress” that the VA and the CM had from the ongoing concerns with the VA’s care and services that were not provided to the VA upon moving to the facility. P1 also said that P2 would be “taking over [the VA’s] case from this point forward.” A Notice of Service Termination letter dated November 25, 2025, stated that the VA’s service initiation date for receiving ICS services from the facility was October 2025 and the facility was terminating the VA’s services effective January 26, 2026. The letter also stated that the termination was “not due to any actions or behavior of [the VA], but wholly due to our inability to secure adequate staffing resources in this region to safely and consistently provide services.” The VA and the CM, and the VA’s Case Notes completed by the CM provided information that was consistent with the emails and text messages and the following additional information: · On October 2, 2025, the VA met with P1 for a tour of the facility. Shortly thereafter, the VA told P1 that s/he would like to “move forward” with his/her placement into the facility’s ICS setting and the VA asked P1 when s/he would be able to move into the apartment. P1 “recommended” a “tentative move-in” date of October 15, 2025, and told the VA that it “might take a week or two” to hire/train the staffing that was needed to provide the VA with adequate ICS services. The VA told P1 that s/he “understood” and would work on getting his/her “things unpacked” and “set up” until a staff person was hired and able to start working with the VA. Additionally, the VA stated that s/he was “blind but not incapable.” However, the CM and the VA each noted that some of the daily living activities that the VA was “typically self-sufficient” at maintaining were also dependent upon what was “expected” from a licensed ICS setting and service provider. The CM said that after P1’s initial conversation with the VA, P1 communicated with the CM via email that a “direct support professional” would be “arranged” to help the VA on “move-in day” (October 22, 2025) and in a later discussion on October 20, 2025, that the start date for services to begin was October 24, 2025. · The VA and the CM each stated that multiple attempts were made to contact and talk to P1 and P2 relating to staffing for the VA and concerns resulting from the VA not receiving the services s/he needed and as required by the VA’s care plans. The VA and the CM also stated there were concerns about not receiving important documentation from the facility despite multiple ongoing requests which included a lease agreement (to show “proof of address”) so the VA could reapply in the new county/city. · Between October 30 and November 3, 2025, the VA contacted P1 multiple times but P1 did not respond and the VA still had not received access to his/her medications that were delivered to the facility’s mail room. At some point during this time, the VA’s medical healthcare provider (MHP) contacted the VA because s/he had reviewed the VA’s daily blood pressure readings and had concerns about the VA’s insulin levels. The VA told the MHP that s/he “ran out of insulin” so the MHP prescribed the VA’s medications to be filled at the “nearest” Walgreens which was approximately 1.1 miles from the facility. The VA then walked to Walgreens by listening to his/her phone GPS directions and using his/her cane and picked up his/her medications. The CM was later notified by the MHP about the VA’s health concerns and the CM “immediately” contacted the VA for a health/safety check who updated the CM about his/her situation. After talking with the VA, the CM attempted to contact P1 but P1 did not respond. · On November 4, 2025, the VA talked to the PM again about receiving a key to his/her mailbox but the PM told the VA that s/he was not able to give the VA a key because P1 had not yet contacted the PM about the matter. The next evening (November 5, 2025), the PM taped the mailbox key to the outside of the VA’s door. The VA then went to the area where the mailboxes were located but discovered s/he needed assistance to locate and open his/her mailbox. The next morning, the VA requested help from an unknown person within the building to open his/her mailbox. The VA’s medications were not there so the VA contacted his/her healthcare provider and confirmed that the VA’s medications were mailed and delivered to the facility. The VA attempted to call and ask P1 for help but P1 did not answer so the VA approached an unknown neighbor (N) and asked the N where packages were delivered. The N told the VA there was a mail/package room where all packages were delivered and that a code was needed to enter the room. The N also said that each resident was notified by email when a package was delivered with a one-time code that was then used to enter the mail room to get the package. After speaking with the N, the VA went to the PM’s office to ask for the mail room code but the PM said that this information was sent to the facility’s main email address and that the VA needed to contact P1 for further assistance. The VA then text P1 but P1 told the VA to contact P2. The VA did so, but P2 did not respond to the VA at that time. Before returning to his/her apartment, the VA told the PM that s/he liked the apartment/community but did not receive any assistance from the facility’s administrative staff and asked if the PM would be “willing” to work with another company who was more responsive to its clients. At some point after this, the PM told P1 what the VA said which “apparently embarrassed” P1 who then called and told the VA that s/he was going to “kick [the VA] out of the program.” The VA stated that s/he was “frustrated” with not receiving adequate communication or help from the facility for things that s/he needed and was “supposed to be provided” and that s/he did not say anything that was “threatening” to the PM or P1. · Around 10:10 a.m. on November 7, 2025, the VA went to the mail/package room after receiving a mail code from P1 but the device was not an accessible device for persons who had visual impairments and so the VA asked an unknown person nearby for assistance but the code did not work. At some point later after receiving an updated mail code from P2, the VA then asked the N for help in entering the code, accessing the room, and selecting the correct packages that were addressed to the VA. The VA stated that one of the medications was to be kept frozen and the VA had 12 hours from delivery to getting it stored in his/her freezer. However, because of the inability to access his/her mail and the mail/package room, the VA had to throw away the medication and s/he paid almost $900 out-of-pocket because the VA’s health insurance would not cover the costs to replace the medication. P1 and P2 provided information that was consistent with the information provided in the emails and texts regarding the VA moving into the facility. P1 and P2 also provided the following additional information: · On October 2, 2025, P1 talked with the VA in-person during the tour of the facility that it “might” take “some time” for staffing/ICS services to become available to the VA and the VA said that “it was fine.” So until the facility was able to hire/train a staff person to work with the VA, the facility/license holder only “established” and maintained a “landlord/tenant relationship” with the VA. The VA did not receive a residency/lease agreement from the facility or ICS services until January 28, 2026. [Note: As previously stated, the Notice of Service Termination letter dated November 25, 2025, stated that the VA’s service initiation date for receiving ICS services from the facility was October 2025 and the facility was terminating the VA’s services effective January 26, 2026.] P1 stated that the VA’s situation occurred “under limited” and “extraordinary circumstances” and that a lease agreement and initiation of services “typically” began on “the same day” that a client moved into the facility’s ICS setting. · P2 stated that administrative staff were responsible for reviewing a potential client’s care plans and “assessing” if the person was a “good fit” for the facility’s programming prior to completing a tour and a service agreement with that person. [Note: According to the DHS electronic data management system, P1, P2, and P3 were administrative staff persons.] Additionally, administrative staff persons “originally” told the CM that there was a person (later determined to be P5) who was in the process of being hired by the facility and was “potentially” “available” to begin working with the VA upon his/her arrival to the facility. However, P5 stopped communicating with the facility for unknown reasons at the same time the VA moved into his/her apartment/facility. · P1 and P2 each stated that “the management team” (P1 and P2) maintained communication with the VA and the CM during their ongoing attempts to hire staffing for the VA, but hiring staff persons was not successful despite P1’s and P2’s continued time and efforts that “exhausted all resources.” There was a “new” person “every day” who showed “initial” “interest” in working with the VA but then each person stopped responding to P1 and/or P2 after interviewing with administrative staff persons and/or meeting the VA which was a “cycle” that lasted for approximately 3 weeks. There were also multiple unidentified “potential staff persons” who met with the VA in-person, completed background study requirements, and/or were “approved” to begin working at the facility but then each person did not “show up to work” his/her “first” scheduled shift as “agreed upon.” However, P2 then provided conflicting information stating that there were not any “potential” staff persons who completed a background study or trainings because “they never got that far” in the hiring process. · P1 and P2 were “transparent” and communicated multiple times to each the VA and the CM that the facility was not able to find/hire adequate staffing for the VA which was discovered and identified at that time as a “known issue” within the Duluth area and not a “suitable” place for the VA to live. P1 later stated that the concerns relating to hiring staff within the Duluth area were resolved at the end of December 2025 after offering an increased hourly wage for the job position in working with the VA. · P1 stated that the VA was “functionally blind” and that “outside the issue of the [mail] room,” there was not an “extraordinary issue” that resulted from the VA not receiving staffing and/or ICS services from the facility after moving into his/her apartment. P1 and P2 each stated that the VA was provided a code to access the mail room within a “couple of days” after the VA requested this information from P1 and/or P2 and that concerns relating to the VA not receiving these codes to access his/her packages was due to the VA’s “misunderstandings” between the key to his/her mailbox and the access codes to the mail room. P1 also stated that the facility was not responsible for issuing keys/key fobs to facility clients because this was done by the PM and that the VA was issued a key within seven days of contacting and informing administrative staff persons about the situation which P1 said was a reasonable timeframe given the process of having the key made/programmed and then delivered to the VA. · P1 stated that although the Notice of Service Termination letter stated that the VA’s services began in October 2025, services were not actually initiated because services had not yet been provided or billed for the VA. According to P2, the VA’s termination of services was caused by “unforeseen” “issues” with hiring staff in this area of Minnesota and was not a standard practice of the license holder. However, at some point during the end of December 2025 or the beginning of January 2026, P1 stated that the facility rescinded the VA’s termination of services because the facility was able to “identify” and hire staffing for the VA and therefore, was able to start providing ICS services to the VA once the staff person (later determined as P9) completed background study and training requirements. Facility documentation provided some information that was consistent with the information provided by P1 and P2. Facility documentation relating to this investigation, including written responses completed by the license holder to questions asked by this investigator, and the facility’s Internal Review (IR) completed by P1 and P2 dated December 31, 2025, also provided the following additional information: · On October 30, 2025, the VA contacted and notified P1 via text message that s/he did not have a key to his/her mailbox. However, documentation was inconsistent regarding when/how P1/P2responded. According to the IR, administrative staff contacted the PM later that day requesting the VA’s mailbox key to be issued to the VA because the facility did not “directly issue keys” as key “activation and distribution were handled” by the PM and through his/her “contracted vendor.” The mailbox key was then provided to the VA on November 5, 2025. Additionally, the IR stated that the facility’s “move-in procedures” did not include a “specific checklist ensuring that essential access items (mailbox keys, building access codes, package retrieval procedures) are confirmed and operational before or immediately upon move-in.” However, facility documentation relating to this report including a “comprehensive timeline of events” stated that P1 was on a medical leave at this time and was not aware of the situation until the morning of November 5, 2025, which was when P1 contacted the PM for a replacement key. At approximately 1:52 p.m., the PM confirmed that the VA’s key would be placed in an envelope and taped to the VA’s apartment door “before the end of [the] business [day].” Later that evening, the VA received the key to his/her mailbox which “resolved [the VA’s] medication and mail access concerns.” · Between October and December 2025, the facility showed “continued efforts” in hiring “suitable” staff for the VA but the “repeated” attempts were not successful. During this time, P1/P2 remained “available on-call” to the VA “24/7” and “responded to [the VA’s] communications consistently, coordinated property access, addressed safety concerns as they arose, and did not bill for 1:1 services that could not be provided.” A “timeline of employee recruitment attempts” stated that from November 10 to 19, 2025, administrative staff persons contacted with five “potential staff persons” which included two unidentified persons (later determined to be P6 and P7) who each met with the VA at the facility during mid-November within a day of talking to P2 about their respective interest in working with the VA. After P6 and P7 each met with the VA, each was “scheduled” to begin working with the VA the following day. However, neither P6 nor P7 “showed up” for their “first day” and “quit” before providing services to the VA. The facility’s Admission Criteria Policy updated by P4 on August 1, 2025, provided the following information: · Before a person could be placed/admitted into the facility’s ICS setting, the facility was required to determine how the person was eligible to receive ICS services from the facility, what services were to be provided, and whether the facility was able to deliver these services to the person in a manner that consistent with his/her care needs and support plan. The facility was to then provide this information to the person or the person’s legal representative as part of the facility’s “pre-admission” process. · Service initiation was to be completed for each person/client who resided in the facility’s ICS setting and received ICS services which consisted of the facility providing the client or his/her legal representative with a written residency/lease agreement. Within five business days of service initiation, the facility was to also provide documentation of the client’s rights. Additionally, a copy of the facility’s policies and procures relating to grievances, service suspension, service termination, emergency use of manual restraints, and data privacy was to be provided to the client/legal representative and the client’s case manager. · The facility was to assess its program capacity and ability to serve a person based upon the facility’s staffing resources, physical environment, and service delivery model that considered the level of care that a person required in relation to the following items: - the availability of qualified staff with appropriate training; - staff-to-person ratios needed to ensure safety and quality services; - compatibility with other persons served; - and alignment between a person’s assessed needs and ICS service categories. The facility’s Program Abuse Prevention Plan stated that the facility maintained a staffing pattern consistent to the individual care needs of each client. The facility’s Health Service Coordination and Care (Residential Programs) Policy stated that the facility maintained the health service needs of each client in a manner that was consistent with his/her support plans. Additionally when a client’s support plan/addendum specified that the facility was responsible in meeting the client’s health service needs, the facility documented how the client’s needs would be maintained including policies and procedures that addressed: how medication assistance/administration was safely provided to the client; how the client’s health conditions were monitored in accordance to written instructions from a licensed healthcare professional; how the facility supported/assisted with the client’s health-related appointments; and how to “safely and correctly” use a client’s medical equipment and/or adaptive devices in accordance to written instructions from a licensed healthcare professional. The facility’s Grievance Policy stated that facility clients had the right to receive respectful and responsive services. During times when there was a grievance with the support/services that a client received from the facility, the client or his/her care team was able to “formally” “bring forward” the concern(s) to facility staff persons by following the facility’s “simple complaint process” that addressed and resolved such grievances in a “timely manner.” Additionally, any grievances that were not adequately responded to/resolved were to be brought to the attention of P4 who was considered the “highest level of authority in this program” and could be contacted using the license holder’s main email address. Regarding services January 2026 and ongoing: The facility developed and maintained a client file in January 2026 and included the VA’s Coordinated Service and Support Plan Addendum, Release of Information Authorization, Health Record, Service Recipient Rights, Individual Abuse Prevention Plan, Intensive Support Self-Management Assessment, and Residency Agreement each dated January 28, 2026. P1 and facility documentation, including P1’s correspondence with the VA and the CM via email; the VA’s updated client file completed by an administrative staff person (P8) dated January 28, 2026; written responses completed by the license holder to questions asked by this investigator; the IR; and P9’s personnel file provided the following information: · On December 29, 2025, administrative staff persons (P1 and/or P2) were able to “identify a qualified staff member” (later determined as P9) and “initiated” a background study and trainings required for the position and to provide direct care services to the VA within this licensed setting. · P9’s personnel file did not contain documentation related to the VA or P9’s date of hire. However, P9 electronically signed tax related documents for job eligibility that were each dated January 2, 2026. At that time, P9 also signed the facility’s Policy Receipt Signature Page but the form was not completed further than P9’s signature and was intended for facility clients and their respective guardians and case managers to complete. [Note: P9’s background study request was submitted on January 5, 2026.] · On January 6, 2026, at 9:16 a.m., P1 emailed the VA and the CM requesting a meeting to “discuss a correction intake” as the facility “prepared to begin ICS services for [the VA].” A meeting was then scheduled for January 9, 2026, at 10 a.m. However, the morning of the meeting, P1 emailed requesting to rescheduled to the following week because P1 was “hoping” that P8 would also be able to attend but was not available that day. The meeting was rescheduled to January 13, 2026, but P1 was “running about ten minutes late” that morning due to a separate and conflicting meeting that s/he was also attending around that time. The meeting was then discontinued shortly after it began and before P1 was able to join the call with the VA, the CM, and P8 due to concerns regarding the VA’s rights to data privacy. P8 told the CM and the VA that s/he was contracted to help the facility complete “paperwork” and accessed the VA’s private health information without the VA’s permission and/or completing a signed Release of Information to do so. [Note: Information regarding P8’s role at the facility conflicted regarding whether P8 was an administrative staff person or a person contracted to provide administrative assistance/guidance.] During the morning of January 18, 2026, P1 emailed the CM and the VA to “apologize” for the “confusion” regarding P8’s role at the facility and to “clarify” that P8 was an administrative staff person employed by the LH. · On January 28, 2026, a video call was held with the VA, P1, P8, and the CM to talk about the VA’s ICS services including what the VA could “expect” from these services and his/her “rights and protections as a client.” The VA was also provided information regarding person-centered planning and service delivery requirements and the facility’s policies and procedures. Additionally, P8 completed the VA’s “intake paperwork” and care plans with the VA which dated the VA’s “admission” and “service initiation” as January 28, 2026, and included the VA’s Coordinated Service and Support Plan Addendum, Release of Information Authorization, Health Record, Service Recipient Rights, Individual Abuse Prevention Plan, Intensive Support Self-Management Assessment, and Residency Agreement. The VA had 1:1 staffing and four hours of ICS services per day, seven days a week totaling 28 hours of services provided to the VA each week. [Note: According to the MN DHS website, the nature of ICS was meant to be flexible, allowing a person receiving ICS to determine his/her own schedule with the ability to change it as needed. Although there can be minor adjustments with the hours a person receives at times, on average, a provider must deliver the number of authorized support hours during that week.] · On February 1, 2026, P1 sent the VA a text message shortly after 10 a.m. with a link to a tenant portal that allowed the VA to pay rent for his/her apartment with a “start date” shown as that same day. · P1 stated that after the VA’s service initiation date, the VA was “offered” the number of authorized support hours each week (28 hours) but there were multiple unknown dates/times during February 2026 when the VA did not receive direct care services because the VA did not “want” services that day. P1 also confirmed that P9 was the only staff person who was currently hired/trained to work with the VA. The VA and P9; correspondence (emails and text messages) between P1, P2, the license holder’s main email address, P9, and/or the VA; and the facility’s DHS background studies roster provided the following information: · On December 29, 2025, P9 received a phone call from P2 about a job opening working at the facility with the VA for which P9 “recently” responded with interest to. During the call, P2 “interviewed” P9 for the job but told P9 that it was “ultimately” a client’s decision whether to hire a staff person and that the VA was able to conduct his/her own “interview” with P9 to determine this. P2 then facilitated communication between the VA and P9, scheduled a date/time for P9 to meet with the VA at the facility, and provided the VA and P9 each with the other’s contact information for further communication outside of P2’s involvement.
· On December 30, at approximately 11 a.m., P9 met and talked with the VA at the facility, and each agreed to move forward with hiring P9 to work with the VA to provide the VA’s weekly ICS services. The VA and P9 each contacted and notified P2 with this information. On January 14, 2026, P9 completed his/her background study and at some point, around this time, P9 also received an email containing staff training on the facility’s policies and procures that s/he completed online. · P9’s “first official” shift in working at the facility with the VA and providing services was on January 7, 2026, from approximately 10:30 a.m. to 12:30 p.m. The VA and P9 provided consistent information that each enjoyed working with each other, “got along well,” and attempted to “work around” the other’s schedule when planning services each week. Additionally, P9 “mostly” worked with the VA on Mondays and Wednesdays each week and “sometimes” Sundays, with the schedule “fluctuating a little bit.” When this investigator asked about P9’s ability to provide the VA with the necessary 28 hours of services each week, the VA and P9 each stated that there were times when services were not provided due to the VA and/or P9 not feeling well and/or having personal matters to attend to but “otherwise” P9 tried his/her “best” to be “available” at times when the VA requested services/assistance. The VA stated that if s/he needed help, had a time-sensitive task, and/or was in an “urgent” situation, despite P9’s children, multiple jobs, and being “constantly busy,” P9 would “find a way” to “come help [the VA] right that second,” “even if it meant bringing [his/her] kids” with on occasion. The VA also stated that P9 was a “human being” and that s/he “understood” that P9 could not be available to him/her at “all” times.
· The VA stated that there were times throughout January and early February 2026 when s/he needed his/her full amount of service hours and P9 was not available and the facility did not have staffing to provide those services. There were multiple dates/times when the VA did not have food because s/he did not have staffing/transportation available to safely access the community which resulted in the VA paying his/her neighbors and/or shopping/delivery services to assist the VA in completing activities of daily living that s/he was supposed to be receiving assistance with from the facility on a daily basis. The VA also stated that s/he did not want to “push” these concerns further because it would cause P1 to become “mad” and “threaten to kick [the VA] out” of the facility “again.” P9’s timecards showed the following information: · On January 7, 2026, P9 began working with the VA with an average of services provided two days per week from January to March 2026. · January 11 to 17, 2026, P9 worked 13 hours with the VA. · January 18 to 24, 2026, P9 worked 7.5 hours with the VA. · January 25 to 31, 2026, P9 worked 12 hours with the VA. · February 1 to 7, 2026, P9 worked 11 hours with the VA. · February 8 to 14, 2026, P9 worked 8 hours with the VA. · February 15 to 21, 2026, P9 worked 12 hours with the VA. · February 22 to 28, 2026, P9 worked 18 hours with the VA. · March 8 to 14, 2026, P9 worked 15 hours with the VA. · March 15 to 21, 2026, P9 worked 9 hours with the VA. · March 22 to 28, 2026, P9 worked 6 hours with the VA. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1 states that the license holder must provide services as assigned in the support plan and the provision of services must comply with the requirements of this chapter and the federal waiver plan. Minnesota Statutes, section 245D.07, subdivision (1), paragraph (a), stated that the license holder was responsible for providing services assigned in the support plan or the support plan addendum, consistent with the person’s identified needs, interests, preferences, and desired outcomes. Minnesota Statutes, section 245D.05, subdivision (1), paragraph (b), stated that the license holder was responsible as assigned by a person’s support plan or support plan addendum to provide medication assistance in a manner that enabled a person to self-administer medication or treatment when the person was capable of directing the person's own care, or when the person's legal representative was present and able to direct care for the person. Minnesota Statutes, section 504B.111, stated in part that a landlord of a residential building with 12 or more residential units must have a written lease for each unit rented and a landlord who fails to provide a lease, as required under this section, is guilty of a petty misdemeanor. Alleged Licensing Violation: It was reported that the facility provided the VA with transitional services when the VA moved into the facility’s ICS setting. According to Minnesota Statutes and the Federal Waiver Plan transitional services must occur from a provider who does not have direct or indirect financial interest in the property and therefore, the VA was not to receive transitional services from the facility. Minnesota Statutes, section 245D.07, subdivision 1 states that the license holder must provide services as assigned in the support plan and the provision of services must comply with the requirements of this chapter and the federal waiver plan. The VA and the CM; the VA’s Case Notes completed by the CM; and consistent documentation provided by the VA, the CM, and the facility regarding correspondence between the VA, the CM, P1, and multiple transitional service providers included the following information: · The VA was initially scheduled to move into the facility on October 15, 2025, but this was delayed because the CM was not able to find a transitional service who was able to help the VA move from his/her current residence into the facility within a timeframe and budget that would meet the VA’s needs. From October 9 to 20, 2025, P1 contacted the CM and the VA multiple times via email and phone about a “professional moving company/service” that the facility had worked with previously, that would be “completely” “organized” by P1, and that the facility “usually requested reimbursement from the transitional provider” upon completion of the move. During this time, the CM had ongoing communication with the VA, P1, and multiple transitional service providers to coordinate the costs and logistics of the VA’s move but continued to “struggle” to find services that met the VA’s needs. On October 20, 2025, P1 told the CM that s/he would “check in with [the facility’s] moving company” that was used previously by the other licensed ICS settings operated by the same license holder as the facility. P1 later confirmed that this “moving company” would be able to help the VA move on October 22, 2025, at 10 a.m. for an estimated quote that would allow the VA to use his/her transitional funds to cover the costs relating to the move, his/her security deposit, and furniture items that the VA had previously told P1 s/he needed and the VA agreed. · On the morning/afternoon of October 22, 2025, three unknown persons who the VA stated were “hired” by P1, helped the VA move into the facility’s apartment. After moving in, the VA contacted and notified the CM that the VA “loved” the apartment and the “Duluth area itself” but also told the CM about “how unprofessional the movers” behaved and that many of the VA’s personal items and furniture (including the VA’s TV that was needed for his/her assisted technology) were damaged. The VA also had contact with P1 throughout the move, the next morning, and ongoing after this via phone, text message, and email about these concerns including photos of the damaged items. · The VA and the CM each stated that multiple attempts were made to contact P1 and the license holder’s main email address to obtain information from/about the “moving company” including an invoice for the move which was time sensitive for reimbursements to be approved. On November 7, 2025, the facility gave the CM a copy of the invoice for these services that was billed to the VA with a payment requested from the facility for $1,636 and included fees for a U-Haul truck rental, labor, fuel and equipment, and administration/coordination of these services. P1 provided the following information: · The facility helped provide moving services to the VA because the VA could not find another company to move the VA into the facility within a timeframe and budget that met the VA’s needs. On October 22, 2025, the facility rented a moving truck and hired “independent contractors” (IC) to help the VA move. Shortly thereafter, the VA contacted and notified P1 that the IC damaged his/her furniture so P1 contacted an “[unspecified] organization” to request reimbursement for the damaged items but the request was denied because the LH did not “contract” with this organization prior to the move, which was information that P1 was not informed of. P1 then stated, “if we knew that we had to go through an application and contract process, we would have never done it.” Additionally, “all the confirmation” P1 received about “hiring out” this work “under [the LH]” was from the CM who said that the LH would be reimbursed and “paid” for the “moving costs” accrued in helping the VA move. However, this was not done and was “completely […] at the cost of [the LH].” · P1 later provided information that P4 was present and coordinated/supervised the VA’s move which was completed by two “movers” (M1 and M2) who the facility contracted for hire but did not have prior experience working with. Additionally, P1 stated that M1 and M2 were “paid in cash” for this work and only knew each by his/her first name and did not have any contact information. According to Minnesota Statutes and the federal waiver plan, if a person moved to a home where ICS services were available, the person must receive transitional services from a provider who does not have direct or indirect financial interest in the property and therefore, cannot receive transitional services from the ICS provider. Given that the VA, the CM, and P1 provided consistent information that the facility coordinated and moved the VA into the facility it was determined the facility provided moving/transitional services for the VA’s move into the facility. Therefore, a licensing violation was determined. Conclusion: A. Maltreatment: Regarding the VA’s lack of services between October 22, 2025, and January 2026: Information obtained from all sources showed that on September 30, 2025, the CM contacted the facility for general information relating to the living arrangements, expenses, and placement availability for the VA to receive services at the facility’s ICS setting. Shortly thereafter, P4 responded to the CM and then communicated with both the CM and the VA in confirming availability and scheduling a tour of the facility for the VA and P1 on October 2, 2025. From October 3 to 21, 2025, P1 maintained continued contact with the VA, the CM, and transitional providers to coordinate the VA’s placement and services at the facility. Additionally, P1 received copies of the VA’s care plans that showed the VA’s diagnosis, history, and care level/needs that the facility was to provide in maintaining the VA’s health and safety. On October 22, 2025, the VA moved into the provider-controlled ICS setting. The VA’s care plans were provided to P1 by the CM prior to the VA’s placement at the facility and showed that the VA had “almost a complete” loss of vision that occurred within the past year so the VA was not able to “independently” complete tasks/activities of daily living within the home and community that s/he was previously capable of and had to “learn” “new” skills and “adjust” to “new” ways of doing things which included assistance from others. This caused the VA to “sometimes” “struggle” with being “overwhelmed,” “frustrated,” “quick to anger,” withdrawing from others, not wanting to leave his/her apartment, and having “a lot of anxiety, especially when [s/he] had to go somewhere [alone] due to not being able to see.” Although the VA was able to live independently, the VA had limitations on his/her abilities to complete daily living/community activities due to the VA’s loss of vision and other health conditions. P1 completed the VA’s RMS Worksheet-Integrated Community Supports and Companion Document on October 6, 2025, which showed that the VA’s vision loss and “reduced” independence resulted in the VA having increased “stress and anxiety” and a need for “consistent oversight” from staff persons to maintain the VA’s health/safety. The VA was also not able to “safely” and “independently cross busy streets, navigate stores, or manage public spaces” on his/her own and therefore, accessing the community without staff assistance would place the VA in “danger” and such situations caused the VA “significant stress and fear of harm.” Therefore, the VA received ICS services from the facility consisting of four hours of in-person services and 1:1 staffing, seven days a week that was to begin on October 15, 2025, but later updated to October 22, 2025. The facility was to provide the VA with daily staff support to help the VA maintain his/her independence while staff persons assisted the VA with transportation, community integration and navigation, health and household management, meal preparation, and developing adaptive skills within a new home and community environment. Additionally, staff persons were to help the VA maintain a “clean” and “organized” living environment; manage his/her “regular health routines” which were “easily disrupted” without staff support and “reminders;” and accessing the community daily which included transportation and staff assistance to complete “errands like grocery shopping.” Emails and text messages between the VA, the CM, P1, and P2 provided consistent information that after the VA moved into the ICS setting, the VA and the CM made multiple and ongoing attempts to contact P1 and P2 regarding the VA’s lack of staffing and concerns resulting from the VA not receiving the services s/he needed and as required by the VA’s care plans. There were also concerns relating to the VA not receiving important documentation from the facility despite multiple ongoing requests which included a lease agreement so the VA could reapply and access community resources (such as transportation services) in the new county/city. [Note: This was a violation of the facility’s Admission Criteria Policy and a violation of Minnesota Statutes, section 504B.111.] P1, P2, and facility documentation provided consistent information that the VA had not been provided or billed for ICS services, that P1 and P2 each made multiple and ongoing attempts to find/hire adequate staffing for the VA, and that P1 and P2 were “transparent” and communicated multiple times to each the VA and the CM about the “unforeseen” “issues” relating to the facility’s inability to hire staff in this geographical area. However, given that the VA moved into the provider-controlled setting on October 22, 2025, with the facility’s knowledge of the VA’s service needs, the facility was responsible for maintaining the health and welfare of the VA which included providing the VA with adequate staffing and services as outlined in the VA’s care plans and maintaining ongoing communication/assistance with the VA and his/her care team while the VA lived in a provider controlled setting expecting ICS services. Therefore, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care and services to maintain the VA’s physical, or mental health and 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). Regarding the VA not obtaining access to his/her mail which contained his/her medications: Information obtained showed that on October 22, 2025, the VA moved into the provider-controlled ICS setting. Information from the VA and the CM and email’s was consistent that the VA and the CM made multiple and ongoing attempts to contact P1 and P2 regarding the VA’s lack of a mailbox key and the VA’s inability to get his/her medications including insulin that had been mailed and delivered to the facility, yet at times neither responded to the VA and/or the CM or ensured the VA obtained his/her mail and/or medications. Although P1 stated that the VA had not been provided or billed for ICS services, given that the VA moved into a provider-controlled setting on October 22, 2025, the facility was responsible for ensuring the VA obtained his/her mail key and passcodes that were emailed to the facility so that the VA could obtain his/her medications. However, the VA went 14 days (from October 22 through November 5, 2025) without access to his/her mail box and/or the mail/package room where the VA’s medications had been delivered. At some point during this time, the MHP contacted the VA because s/he had reviewed the VA’s daily blood pressure readings and had concerns about the VA’s insulin levels. The VA told the MHP that s/he “ran out of insulin” so the MHP prescribed the VA’s medications to be filled at the “nearest” Walgreens which was approximately 1.1 miles from the facility. The VA then walked to Walgreens by listening to his/her phone GPS directions and using his/her cane and picked up his/her medications. The CM was later notified by the MHP about the VA’s health concerns and the CM “immediately” contacted the VA for a health/safety check who updated the CM about his/her situation. After talking with the VA, the CM attempted to contact P1 but again P1 did not respond. Given that the VA was living in a provider controlled setting expecting ICS services, the facility had a responsibility to ensure the health and welfare of the VA. Therefore, the VA not obtaining his/her mail key and/or mail/package codes to obtain his/her medications which resulted in health concerns raised by the MHP, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care and services to maintain the VA’s physical health and 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). Regarding the VA’s ICS service hours from January 7 or 28, 2026 and ongoing: According to the VA’s care plans, the facility was to provide the VA with 1:1 staffing and 28 hours of ICS services each week. Consistent information was provided by the VA, P9, and facility staff timecards that P9 began working with the VA on January 7, 2026, and worked with the VA about two days per week but less than 28 hours. From January 7 to March 28, 2026, the VA was provided between 6 to 18 hours of services each week. Although P1 stated that the facility initiated services for the VA on January 28, 2026, the VA’s services began on January 7, 2026; that the VA was “offered” the number of authorized support hours each week (28 hours), the VA and P9 provided consistent information that the VA wanted to have his/her full hours but P9 was not able to provide 28 hours of services a week; and that there were multiple unknown dates/times when the VA did not receive direct care services because the VA did not “want” services that day, yet the VA stated that there were times throughout January and early February 2026 when s/he needed his/her full amount of service hours and P9 was not available and the facility did not have staffing to provide those services. Therefore, there was a preponderance of the evidence that the VA was not provided the amount of service hours that s/he was authorized for each week which was a violation of Minnesota Statutes, section 245D.05, subdivision (1), paragraph (b); and section 245D.07, subdivision 1, paragraph (a). However, given that the VA was provided with between 6 to 18 hours each week; that the VA stated that if s/he needed help, had a time-sensitive task, and/or was in an “urgent” situation, despite P9’s children, multiple jobs, and being “constantly busy,” P9 would “find a way” to “come help [the VA] right that second,” “even if it meant bringing [his/her] kids” with on occasion; and that the VA was able to make arraignments with neighbors and/or delivery services when s/he was out of food; there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care. 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). 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 facility was responsible for the health and welfare of the VA who lived in the facility’s ICS setting, in addition to ensuring maintaining compliance with Minnesota Statutes including hiring staff persons to provide the VA with ICS services as assigned by the VA’s care plans. Therefore, the facility was responsible for the neglect of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious. Action Taken by Facility: The facility’s Internal Review stated that the facility’s policies and procedures were followed but were not adequate, identifying a need for revising the facility’s client admission policies, updating the facility’s procedures relating to staff hiring/training, and establishing a designated manager. Action Taken by Department of Human Services, Office of Inspector General: On June 5, 2026, the facility was issued a Determination of Maltreatment. Based on the determination of substantiated maltreatment and the nature of licensing violations determined during the investigation and during a licensing review conducted on April 8, 9, and 17, 2026, an Order of License Revocation was also issued. The maltreatment determination and the revocation are each subject to appeal.
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