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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: 1115821-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lisa Shock Lisa.shock@state.mn.us 651-431-6142 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) left without staff person’s (SP) knowledge and/or supervision and was found in the community by law enforcement with no socks, shoes or coat on. Date of Incident(s): February 27, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 1, 2026; from documentation at the facility and law enforcement records; and through five interviews conducted with a supervisory staff person (P1), three staff persons (the SP, P2 and P3), and the VA’s guardian (G). Attempts were made via phone and email to contact and interview another staff person (P4), but P4 did not respond to the requests. P4 provided information for the internal review and that information is included below. This investigator also met the VA but due to his/her limited communication skills, s/he was not interviewed for this investigation. The VA was diagnosed with Down syndrome and autism. The VA enjoyed going for walks, playing outside, listening to music and playing Uno. The facility was a rambler home with a basement located in a residential neighborhood. The main level consisted of a kitchen, living room, bathroom, three bedrooms, and an office. The office was located directly off of the living room and had a door that locked. There were three doors in the facility leading outside. One door in the office that led to the front of the home, one door in the living room that led to the fenced back yard with a gate that could not be opened from inside the yard, and one door in the kitchen that lead into the garage. All three doors that led outside had an alarm and required a badge to open when coming into the facility. When the doors were opened from the outside without a badge and every time the doors were opened to go outside, a “long beep” sounded. The VA’s Individual Abuse Prevention Plan stated that the VA must be in visual range of staff “at all times” while in the home and community. The VA was impulsive and ignored personal safety. The VA would not be able to choose weather appropriate clothing without staff assistance. The VA had a history of leaving the facility unsupervised. If the VA left unsupervised, staff persons were to go out and look for the VA. Four clients (C1-C3 and the VA) lived at the facility and each had 1:1 staffing and on occasion there was an additional fifth staff person. On February 27, 2026, P1-P4 and the SP were scheduled to work. The Schedule Report showed that on February 27, 2026, P1-P4 and the SP were working. P1-P3 and the SP and the facility Staff Assignment Log and Internal Review provided the following different information regarding who was the VA’s 1:1 at the time of the incident (February 27, 2026): · P1 provided conflicting information regarding the VA’s 1:1. During his/her interview with this investigator, P1 stated that the SP was the VA’s scheduled 1:1 and provided the Staff Assignment Log as below. However, in the Internal Review, P1 stated that there was not a schedule of supervision assignments on February 27, 2026, and “everyone was helping everyone.” · P2 stated during his/her interview that s/he did not know who was the VA’s 1:1 and provided information in the Internal Review that there was not a Staff Assignment Log for the day. · P3 and the SP each provided consistent information during their respective interviews and in the Internal Review that there was not a Staff Assignment Log for 1:1 assignments for the day and/or at the time of the incident. · P4 provided information in the Internal review that on the day of the incident s/he did not know who was scheduled as the VA’s 1:1. · The Staff Assignment Log stated that the SP was scheduled as the VA’s 1:1. Law enforcement records stated that on February 27, 2026, at 2:56 p.m., law enforcement (LE) responded to a call of a person with no socks or shoes on standing in the middle of the street. At 2:58 p.m., LE located the VA at an elementary school. [Note: The elementary school was approximately 0.3 miles from the facility and located across the street. According to google maps, this was a seven-minute walk.] The VA was wearing pants and a T-shirt, no socks, shoes or jacket and had no notable injuries. LE determined where the VA lived and drove the VA back to the facility. LE met several staff persons outside of the facility who had been looking for the VA. LE left the VA with P1. According to www.wunderground.com, on February 27, 2026, at 3 p.m., the temperature in Plymouth, MN, was 50 degrees Fahrenheit, no precipitation and the conditions were fair. P1, P2, and P3 provided the following information: · P1-P3 each stated that the VA required 1:1 supervision and needed to be within auditory or visual range at all times. · P1-P3 and the SP each stated that P1 was responsible for making the daily staff assignment log and that when staff persons arrive they check the schedule. · P1 stated that on February 27, 2026, at an unknown time, s/he was in the office when C1 needed assistance in his/her bedroom. P1 then left the office to help C1 but did not close or lock the office door. Shortly after the SP also went into C1’s bedroom. · P3 stated that around 2:45 p.m., s/he was in the kitchen with the VA and saw P1 leave the office and go into C1’s bedroom. “A couple of minutes” later, P3 noticed that the office door was open and asked P1, why it was open. P1 then asked where the VA was and the SP replied that the VA was in the kitchen folding clothes. Shortly after, the VA went to go put his/her clothes away in his/her bedroom. · P1 said that at some point while in C1’s bedroom, s/he heard a long beep sound indicating that a door was opened but the sound then stopped indicating the alarm was turned off. P2 and P3 stated that they did not hear the alarm sound. · A few minutes later, P3 went to look for the VA but the VA was not in his/her bedroom. P3 then asked to no one in particular, “Where is [the VA]?” P1 and the SP then came out of the C1’s bedroom. P1 immediately ran into the office and then outside while P3 and the SP went out the front door to look for the VA while P2 stayed at the facility with C1 and C2. · P3 had been the VA’s 1:1 staff from 6 a.m. to 2 p.m. [Note: As previously noted above, P1 provided conflicting information regarding who the VA’s 1:1 was and P2, P3, and the SP each stated there was not a schedule for the VA’s 1:1 from 2 to 10 p.m.] · P2 stated s/he was scheduled as the float from 1 p.m. to 8 p.m. [Note: The Staff Assignment Log showed that P3 was scheduled as the float staff person from 2 to 10 p.m.] P2 was in C2’s bedroom with the door closed, assisting C2 with cleaning his/her room. · P1, P3 and the SP were outside and approximately 5-10 minutes later law enforcement arrived with the VA. P1-P3 and the SP did not notice any injuries to the VA and the VA did not require medical attention. · P1 stated that once it was noticed the VA was not in the facility, s/he believed the VA had left through the office door. P2-P3 and the SP stated that s/he did not know how the VA got outside. The SP provided the following information: · On February 27, 2026, the SP was C1’s 1:1 staff in the morning shift. Around 1:40 p.m., the SP was downstairs refilling a medication for C2 and when s/he came back upstairs the SP noticed that the office door was open and told P1 that it was open. P1 then asked where the VA was and the SP looked and saw the VA folding laundry in the kitchen with P3. · The SP then went into C1’s bedroom and shortly after the SP was in there, P3 asked where the VA was. The SP replied that the VA was folding clothes in the kitchen and P3 responded that the VA was not in the kitchen. The SP stated that s/he did not hear the alarm sound at any point. · The SP, P1, and P3 then went outside to look for the VA while P2 remained at the facility with C1 and C2. P1 went out the office door and the SP and P3 went out the front door. An unknown amount of time later the VA was brought back home by LE. · The SP stated that the VA needs to be in visual range at all times. The VA was “very fast” and needs to be supervised. The G stated that on February 27, 2026, at 3:30 p.m., P1 notified the G that the VA left the facility without supervision and was found by LE across the street at an elementary school. The VA had a history of leaving without staff supervision but it had not happened in a “long time.” The VA was “very fast.” The G did not have any concerns regarding the care and supervision provided by the facility and the VA did not require medical attention afterwards. All staff persons interviewed and P4 were trained on the VA’s plans and Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, which states, in part, the license holder must provide services in response to a person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum as required. Conclusion: A. Maltreatment: The VA’s Individual Abuse Prevention Plan stated that the VA had 1:1 supervision and must be in visual range of staff at all times while in the home and community. The VA had a history of leaving unsupervised and was impulsive and ignored personal safety. Information from all sources was consistent that on February 27, 2026, at an unknown time, the VA left the facility without staff persons knowledge and was unsupervised, which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a. P1 stated that s/he believed the VA left through the back-office door. At 2:56 p.m., LE was notified that a person (determined to be the VA) was standing in the middle of the street with no socks or shoes. At 2:58 p.m., when LEO arrived, the VA was at the elementary school and LEO returned the VA to the facility where staff persons were looking for the VA. Although the VA was not wearing socks/shoes, at the time of the incident it was 50 degrees Fahrenheit, and there was no precipitation and the conditions were fair. Although information was consistent that the VA did not sustain any injuries, given that the VA required 1:1 supervision including being in visual range of the VA at all times due to his/her history of leaving unsupervised, and that the VA was able to leave the facility without staff knowledge and was found in the middle of the street and later at the elementary school, despite five staff persons being present and alarms on the door, and that according to P1 an alarm sounded at some point but there was no information any staff followed up on the alarm, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or services that were reasonable and necessary. 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 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. All staff persons interviewed and P4 were trained on the VA’s plans and Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. The four clients, including the VA, who lived at the facility each required 1:1 staffing. On the day of the incident, five staff persons were working, P1-P4 and the SP. Although P1 told the investigator that the SP was responsible for the supervision of the VA at the time of the incident and provided the Staff Assignment Log that stated the SP was scheduled as the VA’s 1:1, P1 provided information in the internal review that there was not a schedule of supervision assignments on February 27, 2026, and “everyone was helping everyone.” P1’s information in the Internal Review was consistent with the information P2, P3, and the SP each provided that there was not a Staff Assignment Log at the time of the incident. Therefore, it was determined that P1, who was a supervisory staff person, provided false or misleading information regarding the SP being the VA’s 1:1. Information showed that P1 was responsible for making the Staff Assignment Log, however, despite the fact that there was no scheduled 1:1 for the VA, at the time of the incident there were five staff persons working at the facility, P1-P3 and the SP provided consistent information that each was aware that the VA required 1:1 supervision and that each was aware there was not a designated 1:1 for the VA, and P3 was the last person who saw the VA go to his/her bedroom prior to the VA leaving and did not maintain visual supervision of the VA. These factors represented a systemic failure and therefore, individual staff persons responsibility was mitigated and the facility was responsible for the maltreatment of the VA. C. Recurring and/or 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 incident of substantiated neglect for which the facility was responsible did not meet statutory criteria to be determined as serious because the VA did not sustain a serious injury which reasonably required the care of a physician. Action Taken by Facility: All staff persons were retrained on the VA’s plans and supervision requirements. The facility changed the office door hardware to lock when closed and changed the door leading outside to require a code to be entered to exit through that door. Staff persons will keep office door closed and locked when staff persons are not in the office. Action Taken by Department of Human Services, Office of Inspector General: On June 5, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. In addition, it was determined that facility mandated reporters had knowledge of the alleged incident and did not report the incident as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine is subject to appeal.
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