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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: 1124190-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Anna.Parkin@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who was not licensed to drive, left the facility and drove the facility vehicle without a staff person’s (SP1) knowledge/supervision. It was later learned that another staff person (SP2) left the facility vehicle keys in the kitchen and the VA took them. Date of Incident(s): May 28, 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 June 9, 2026; from documentation at the facility, law enforcement records, and medical records; and through nine interviews conducted with two supervisory staff persons (P1 and P2), four facility staff persons (P3, P4, SP2, and SP1), the VA, the VA’s case manager (CM), and the VA’s guardian (G). The VA was diagnosed with autoimmune basal ganglia disorder with brain lesions. The VA’s Self-Management Assessment stated that the VA had a history of leaving the facility unsupervised including stealing vehicles. The VA did not have a valid driver’s license. The VA’s Supervision Needs – Residential & Vocational document provided the following information: · The VA had 1:1 staffing while at the facility. Staff persons were to be within visual range of the VA while in the main areas and yard. Staff persons were within audio range of the VA when s/he was inside his/her bedroom or bathroom. · The VA had 2:1 staffing while out in the community with one of the staff persons within an arm’s reach. Staff persons used “situational awareness skills” when working with the VA. The VA’s Individual Abuse Prevention Plan stated that the VA was “impulsive” and may not process consequences of his/her actions. Staff persons followed the VA’s supervision requirements and discussed with the VA how to stay safe. Staff persons “immediately” intervened and prompted the VA to stop activities that were not safe. The facility had an upstairs where the VA resided and a basement where another resident resided. The upstairs main area included a kitchen, living room, and dining area. There was a door to the garage off the kitchen where the facility vehicle was parked. There was a hallway from the living room that went to the VA’s bedroom and a staff office. All the exterior doors had alarms/alerts that sounded when they were opened. Consistent information was provided that on May 28, 2026, SP2 was the VA’s 1:1 staff person and P2-P4 were also at the facility. SP2 was assigned to work with the VA until 3 p.m. and then SP1 was assigned to work with VA. P2 worked on documentation in the staff office and P3 and P4 worked on other tasks around the facility. The VA provided consistent information during his/her interview and to P1 that on May 28, 2026, at some point after returning from an outing, SP2 left the facility vehicle keys on the island kitchen counter “in plain sight.” While SP2 cooked lunch, the VA took the keys and put them in his/her pocket. Then at 4:06 p.m., the VA told SP1, who was on the couch on his/her cell phone, that s/he was going to take a nap. The VA then walked out of the door to the garage and the alert/alarm sounded, got into the facility vehicle, and left. SP1 was not aware that the VA left the facility. The VA drove around multiple cities, ran a red light, and hit another vehicle. The VA said s/he was gone for approximately two hours because s/he remembered that law enforcement “caught” the VA at 6:04 p.m. The VA told P1 that s/he wanted to go on an “adventure.” The CM stated that the VA had a history of leaving the facility unsupervised so s/he had concerns with how it happened especially with 1:1 staffing. The G had concerns about the VA leaving the facility unsupervised and possibly injured him/herself or other persons. Facility documentation showed that all staff persons were trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Regarding the VA leaving the facility and driving without SP1’s knowledge/supervision: The law enforcement report provided the following information: · On May 28, 2026, at 5:30 p.m., a law enforcement officer (LEO1) was dispatched to a traffic complaint on Main Street in Albertville, Minnesota. The 9-1-1 caller stated that a vehicle (later determined as the facility vehicle) drove “erratically,” possibly hit another vehicle, and ran a red light. Another law enforcement officer (LEO2) saw the facility vehicle driving on State Highway 241 and tried to pull the vehicle over but the driver (later identified as the VA) refused. LEO2 followed the facility vehicle as it was “weaving” in and out of lanes of traffic. · The vehicle eventually stopped. The VA told LEO2 that s/he stole the facility vehicle. LEO2 saw that the front end had “major” damage so LEO2 decided that the VA needed medical attention so the VA was transported to the hospital. · The facility declined to press charges against the VA so law enforcement took no additional action. The VA’s medical records stated that, on May 28, 2026, at 7:30 p.m., the VA was seen in the emergency room for a vehicle collision. The VA said s/he had left shoulder “pain” in the scapular (shoulder blade) area. The doctor completed a physical exam and noted “some limitations in range of motion” of the VA’s left shoulder but later on in the exam, the VA’s left arm moved “freely.” The VA was diagnosed with a possible periscapular muscle strain. There were no images (x-rays) taken and the doctor offered the VA acetaminophen but P2 said they would administer it once they returned to the facility. Information obtained showed that when state-owned vehicles travel over 85 miles per hour the information was recorded and documented. Information recorded from the facility vehicle showed that on May 28, 2026, at 4:22 p.m., the facility vehicle drove more than 85 miles per hour for more than ten seconds. The location was at 13867 Voyageur Highway in Becker, Minnesota. According to googlemaps.com, that location was approximately seven miles from the facility and took approximately 12 minutes to drive. P1 and P2 provided the following information: · On May 28, 2026, after 3 p.m., P2 was in the staff office with the door closed, working on documentation and s/he was not aware of what SP1 and the VA were doing. At an unknown time, SP1 came into the staff office and asked P2 if s/he had seen the VA. P2 and SP1 immediately looked around the facility and noticed that the facility vehicle was missing so P2 called P1. · According to P1’s cell phone, on May 28, 2026, at 5:38 p.m., P2 called P1 and said the VA was not at the facility and asked P1 if the facility vehicle was gone for repairs. P1 stated that the vehicle should be at the facility and directed P2 to call 9-1-1 and P2 did so. · P2 and SP1 then drove around looking for the VA when law enforcement contacted them and said that the VA was at the hospital. P2 and SP1 drove to the hospital where they determined that the VA was not injured.
SP1 provided the following information: · On May 28, 2026, at 3 p.m. SP1 arrived at the facility. SP1 and P2 were the assigned 2:1 staff person but P2 was in the office working on documentation through the whole incident. [Note: According to the VA’s plans the VA required 2:1 staffing in the community and 1:1 staffing at home.] After three minutes of being there, the VA told SP1 that s/he was going to nap and went to his/her bedroom. SP1 sat on the living room couch where s/he was able to see the VA’s bedroom door. At approximately 4:15 p.m., the VA came out of his/her bedroom and sat in the living room. The VA asked to watch television so SP1 turned on the television. · At approximately 4:20 p.m., the VA said s/he was going back into his/her bedroom. As the VA stood up and started walking toward his/her bedroom SP1 stood and walked to the kitchen. SP1 did not see the VA go into his/her bedroom and did not remember if s/he heard the door alarm/alert. SP1 got a snack and returned to the living room. · SP1 sat in the living room until approximately 5:25 p.m., when s/he went to check on the VA and SP1 noticed that the VA’s bedroom door was open. SP1 looked inside the VA’s bedroom and did not see the VA. SP1 then went to the staff office and told P2 that the VA was gone. SP1 and P2 looked around the facility and saw that the facility vehicle was gone. SP1 said that “we” called P1 and then “we” called 9-1-1. · SP1 and P2 drove around looking for the VA and at an unknown time, received a phone call from law enforcement that they were at the hospital with the VA so SP1 and P2 went to the hospital. The VA was seen by a doctor and did not have any injuries. · SP1 was trained that if the VA was in his/her bedroom, SP1 sat on a chair or the couch in the living room and watched the VA’s bedroom door. Approximately every 30 minutes, SP1 checked on the VA while in his/her bedroom. Regarding SP2 leaving the facility vehicle keys in the kitchen: Consistent information was provided that the facility vehicle keys were to be stored inside the locked staff office and inside a locked closet. P1-P4 and SP1 provided the following information: · On May 28, 2026, SP2 and P3 took the VA on an outing in the community. SP2 drove to and from the outing so s/he was in charge of the vehicle keys. At approximately 2 p.m., they returned to the facility and P3 went into the staff office to work on documentation while SP2 stayed in the main area with the VA as the VA’s 1:1 staff person. · P2 stated that SP2 came into the staff office after returning from the outing and P2 asked SP2 how it went. SP2 responded, “Good.” P2 and P4 each stated that at that time, SP2 did not put the vehicle keys in the closet. At approximately 3:30 p.m., P4 came out of the staff office to leave for the day and did not notice keys sitting out anywhere. · The VA provided consistent information to P1, P2, and SP1 that SP2 left them on the kitchen counter so the VA took them. · P1 felt that the VA was accurate about the keys being on the counter and P3 stated that SP2 had a history of being distracted while at work because each stated that SP2 had previously left the facility vehicle keys on the counter. SP2 provided the following information: · On the day of the incident, SP2 and P3 took the VA on an outing and SP2 drove the facility vehicle. At an unknown time, after they returned to the facility, SP2 began preparing the VA’s lunch. SP2 put the vehicle keys on the kitchen counter. After approximately two to three minutes, SP2 picked up the keys and put them in his/her pants pocket because s/he knew the VA had a history of leaving the facility without supervision. · After the VA ate lunch, SP2 took the vehicle keys and put them in the locked closet inside the staff office and then worked on documentation. P2 and P4 were in the staff office during that time. When SP2 finished his/her documentation around 3 p.m., the door to the staff office was left open. The VA had a history of sneaking into the staff office and taking items. SP2 denied leaving the vehicle keys on the counter in the kitchen. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a) states in part that the license holder must provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in in the support plan and support plan addendum. Conclusion: A. Maltreatment: The VA’s plans provided information that the VA had a history of leaving the facility unsupervised and taking vehicles although the VA did not have a valid driver’s license. Therefore, facility vehicle keys were to be locked up and the VA required 1:1 staffing with staff persons within visual range of the VA unless the VA was in his/her bedroom or the bathroom. The VA provided consistent information to multiple people at different times that after returning from an outing, SP2 left the facility vehicle keys on the counter so the VA took the keys. Then around 4 p.m., the VA told SP1 that s/he was going to take a nap but instead left the facility driving away in the facility vehicle. At 5:30 p.m., a 9-1-1 call was made stating that a car, driven by the VA was driving erratically. At an unknown time, after the VA ran a red light, hit at least one vehicle, and drove over the speed limit, LEO2 pulled the VA over and the VA was taken to the emergency room to be evaluated and P2 and SP1 eventually arrived for the VA. The VA obtaining keys that were to be locked up and leaving and being gone from the facility for one-and-a-half hours without staff knowledge, was a violation of the VA’s plans and a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Regarding the VA leaving the facility and driving without SP1’s knowledge/supervision:
Although the VA left around 4 p.m., no staff person realized the VA was gone until approximately 5:30 p.m. (one-and-a-half hours later), at which time, SP1 checked on the VA who was not napping in his/her bedroom and then asked P2 for assistance. Given that the VA required 1:1 supervision at the facility and was able to leave the facility without staff persons knowledge/supervision and was unsupervised in the community for approximately one-and-a-half hours; and that the VA took the facility vehicle without having a valid drivers license and drove around the community running a red light, speeding, hitting cars, and weaving in/out of traffic, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care or services. 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 SP2 leaving the facility vehicle keys in the kitchen: Although SP2 stated that s/he put the vehicle keys back in the locked staff closet, given that P2 and P4 each stated that they were in the office when SP2 came into the office and SP2 did not put the vehicle keys in the closet, that P1 and P3 each stated that SP2 previously left the vehicle keys on the counter, that SP2 had reason to minimize his/her actions for fear of repercussions, and that the VA provided consistent information to more than one person on more than one occasion, it was more likely that the VA obtained the keys after SP2 left them on the counter. Given the VA’s history of leaving the facility and taking vehicles and that the keys were to be locked in a closet in a locked office, yet SP2 left them on the counter accessible to the VA, there was a preponderance of the evidence that there was a failure or omission to supply the VA with reasonable and necessary care or services. It was determined that neglect occurred (The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. SP1 and SP2 were the assigned 1:1 staff person with the VA at the time of the repective incidents. SP1 and SP2 were each trained on the VA’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. SP1 and SP2 were each responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP1 and SP2 were responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident and the VA did not sustain a serious injury. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility completed a structured day outcome that increased engagement and provided predictability to the VA’s day to day activities. The facility updated the Program Abuse Prevention Plan to include specific language about storing the facility vehicle keys. All staff persons received training on the updated Program Abuse Prevention Plan and the VA’s supervision needs. Action Taken by Department of Human Services, Office of Inspector General: SP1 and SP2 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1 and SP2 were each notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in disqualification. The determination that SP1 and SP2 were each responsible for maltreatment is subject to appeal. On July 8, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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