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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: 1124940-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman Deb.Neubauer-Hoffman@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was not supervised resulting in leaving the facility without staff person’s supervision and entering private property on multiple occasions. Date of Incident(s): April and May 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 May 20, 2026; from documentation at the facility and law enforcement (LE) records; and through 10 interviews conducted with the VA, five facility staff persons (P1, P2, P4, P5, and P6), one community person/neighbor (CP2), a county licensor (CL), a case manager (CM), and a guardian (G). Attempts to interview another staff person (P3) were not successful. The VA moved into the facility on March 24, 2026. Prior to that date, the VA resided at a different facility operated by the same organization. The VA was relocated to the current facility due to repeatedly leaving the first facility and engaging in trespassing, especially at local fast-food restaurants, a gas station, and a liquor store. It was determined that a rural setting was more appropriate for the VA. The VA enjoyed fishing, going to movies, smoking cigarettes, and drinking soda. The VA’s diagnoses included schizophrenia, schizoaffective disorder, bipolar type. The VA’s Elopement Protocol stated if the VA left the facility without permission, one staff person followed on foot at a safe distance (10-15 feet) with a second person “further back” for additional support if needed. Staff persons prompted the VA to return to the facility and “must never lose sight” of the VA and monitored with “minimal engagement” to “avoid agitating [the VA] further.” The VA’s Support Plan Addendum (SPA) provided information consistent with the Elopement Protocol. In addition, the SPA stated if the VA attempted to enter a location where s/he had an active no-trespass order, staff persons were to calmly redirect the VA away from the area and encourage an alternative community activity. The facility was in a residential area within a rural setting (gas stations, grocery stores, and fire/ambulance services were within a 10-mile range). The facility was a split-level duplex with an entryway between the two levels. The upper and lower levels were separated by doors on each level, indicating separate living areas. The VA resided on the lower level and no additional residents lived at the facility since the VA’s admission in March 2026. The Department of Human Services received the following information from CP1 and/or CP2: · On April 1, 2026, a community person (CP1), who lived in the VA’s neighborhood, was at home when his/her doorbell was rung repeatedly. CP1 checked his/her security camera and saw the VA on the front steps, visibly agitated and using profane language. Two unidentified staff persons were also present with “blocking pads” and attempted to redirect the VA away from CP1’s home. · On April 17, 2026, the VA was again on CP1’s property and removed an aluminum security sign out of the ground. “A couple minutes” later staff persons were able to get the VA to drop the sign and leave. This incident occurred two minutes after CP1’s young child entered the home after school and “had the timing been slightly different” the child would have encountered the VA outside. · On April 22, 2026, the VA was observed walking into CP1’s yard carrying a stick. Law enforcement was called, and the VA was issued a trespassing citation. · On April 26, 2026, the VA stood at the edge of CP1’s yard staring into the yard where several children were playing. The VA eventually walked away. No staff persons were observed with the VA that day. (Note: A review of the VA’s Service Deliver Log for April 26, 2026, showed that P1 and P2 worked with the VA that day and documentation stated the VA was outside to smoke. The VA went outside to go for a ride with staff persons. Other than that, the VA “declined participating in outdoor activities.”) · On April 30, 2026, CP2 was walking and the VA “started running after” CP2. CP2 called another neighbor to transport CP2 back to his/her home. On that occasion, no staff persons were initially with the VA. CP2 “used to go on walks” every day in the neighborhood but now was “scared.” On other occasions CP2 observed that the VA was “by [him/herself] for a minute or two” before one staff person walked to follow the VA and another followed in a vehicle. Other unidentified neighbors told CP2 that staff persons had to use “body shields” because the VA hits them and s/he was told that a neighbor had “lots of problems” because the VA went onto their property. CP2 asked if the VA could be “relocated.” · On multiple unidentified dates, the VA was observed walking down the middle of the road with staff persons following the VA in a vehicle or walking and carrying “blocking pads” but were “unable or unwilling to prevent [the VA] from entering private property.” The facility and/or law enforcement reports showed the following information: · On March 30, 2026, P2 and P4 were working at 4:16 p.m. when the VA walked out of his/her room and continued out of the facility. One staff person followed on foot while another followed at a safe distance in a company vehicle. After approximately 10 minutes the VA sat on a bench and when an unidentified staff person attempted to redirect the VA back to the facility, the VA began yelling. An unidentified neighbor (determined to be CP3) approached on a bicycle and called the sheriff’s department. Approximately 10 minutes later the VA agreed to return to the facility and while walking back, an officer arrived and stated they were available if needed. Once back at the facility the VA was administered a PRN (as needed medication). · On April 6, 2026, at 2:13 p.m., P2 and P4 were working when the VA picked up a rock and hit the facility vehicle several times and demanded staff persons call law enforcement (LE). The VA threatened to hit P2 and P4 if they did not call 9-1-1. The VA went inside and attempted property destruction with the rock. After 10 minutes the VA was calm and was outside smoking a cigarette when LE arrived and said that a neighbor called about the VA yelling. The LE report stated that when they responded to the facility the VA was “outside with two staff members” and the VA was asking about a court hearing. The VA was “calm with a good demeanor.” · On April 11, 2026, around 11 a.m., two facility reports described two separate incidents at that same time. One report said the VA asked an unidentified staff person if they had a knife and began raising his/her voice. The VA went outside and was yelling, then grabbed a snow shovel from the garage and moved towards staff persons in a threatening manner. Staff persons used “blocking pads” and kept distance between themselves and the VA. The second report stated that the VA threatened to throw rocks at P3’s and P4’s vehicles and when the VA went outside, the staff persons followed. The VA wanted LE to be called and an unidentified neighbor (determined to be CP3) “became involved” and “attempted to intervene.” The VA also threatened to “murder” one of the staff persons. LE arrived and the VA de-escalated. A LE report said a neighbor called due to the VA being outside screaming and staff persons were not able to get him/her to calm down. When LE arrived at 11:48 a.m., the VA and staff persons were inside the facility and the VA was calm. · On April 13, 2026, around noon, P1 and P7 were working when the VA became agitated and wanted a cigarette. The VA was reminded about his/her schedule and that s/he had to “wait” for the cigarette and was offered gum instead. The VA engaged in several incidents of property destruction inside the facility and hit P1 with a laptop computer two times with “full force.” The VA then left the facility without supervision and LE was called. P1 and P7 located the VA at a nearby church “trying to get inside;” however, it was locked so the VA sat on a bench. When LE arrived, the VA was transported via ambulance to a hospital for evaluation. · On April 22, 2026, around 7:40 p.m., P1 and P4 were working when the VA “started having behaviors without any trigger” and went outside and walked to a neighbor’s home, entered their yard, and repeatedly rang their doorbell. LE arrived and documented this was the third time the VA walked on that neighbor’s property in three weeks and that this was the fifth call regarding the VA in April 2026. The VA was issued a trespassing notice. · On April 30, 2026, although CP2 told this investigator that the VA “started running after” him/her, LE documented that CP2 told LE that s/he “did not know if [the VA] was running at [CP2]” or “just happened to be running in [CP2’s] direction.” When CP2 got to the end of the road and turned, the VA turned “the opposite way and did not follow.” CP2 went to a neighbor’s home to request a ride because CP2 was “told” the VA was “dangerous.” LE offered to go to the facility with CP2 to talk to the VA or staff persons and CP2 declined. LE did not see the VA or staff persons outside and left a message for the manager of facility that they were continuing to get complaints about the VA. Facility documentation for that same day showed that when the VA was upset and displayed aggressive behavior, staff persons attempted to de-escalate the VA but were not successful and the VA went outside and left the facility property. P1 and P4 followed the VA and maintained “line of sight” the entire time. The VA went into a neighbor’s driveway and asked a mail carrier to call 9-1-1. The staff persons were able to redirect the VA back to the facility and the VA was resting when LE arrived. · On May 3, 2026, around 2:30 p.m., P2 and P4 were working when the VA wanted to go for a walk. P2 and P4 followed the VA, one on foot and the other in a vehicle. The VA walked to private property behind a local church and was there approximately 10 minutes before the VA agreed to get in the vehicle and return to the facility. On the way back to the facility, LE arrived and said an unidentified neighbor wanted a trespassing notice issued to the VA for being on their property. · On May 24, 2026, around 3:30 p.m., the VA wanted to walk to a local church. P1 and P2 were working and reminded the VA that s/he was issued a trespassing notice for the church. The VA did not listen and walked towards the church with one staff following on foot and one in a vehicle. The VA picked up a rock and swore at three children who then ran into the church. The VA agreed to get in the vehicle and returned to the facility. About an hour later, LE arrived and issued another trespassing notice for the church property. · On May 26, 2026, around 3:25 p.m., P1 and P2 were working and the VA believed s/he had a court hearing that day. The VA threatened P1 and P2 with a toilet plunger if they did not call LE. Attempts to de-escalate the VA were not successful and the VA went outside and yelled resulting in a neighbor calling LE. The VA was administered a PRN and calmed down by the time LE arrived. P1, P2, P3, P4, P5 and/or P6 provided the following information: · P1, P2, P4, P5 and P6 (a management person) each stated that two staff worked with the VA and if the VA left the facility property, one staff followed the VA on foot while the other followed in a vehicle until the VA was ready to accept a ride back to the facility. · P1, P2, P4, P5, and P6 each said that staff persons were always with the VA when s/he left the property and there was never a time the VA left without staff persons being aware. · P1 said that when the VA wanted to leave the facility, staff persons were not able to physically stop the VA and were trained to follow the VA “right away” and attempt to redirect him/her back to the facility. P1 said that the person following the VA “on foot” were not “next to” the VA but walked a couple steps behind the VA because s/he “will get physical.” On some occasions when the VA got “physical,” staff persons used “blocking pads.” P1 said that the VA was always visually supervised by staff persons and s/he was not aware of any times the VA left the property without supervision. · P2 said there were “countless” times the VA left the facility property. The staff person who followed on foot stayed calm and spoke to the VA using a soft voice to de-escalate him/her. Sometimes the VA yelled at staff persons and told them to stop following him/her and on those occasions the staff person gave the VA “more space.” If the VA went on private property, the VA was redirected to leave and if a neighbor came outside staff persons attempted to inform the neighbor that the VA was not a threat, was a client, and staff persons were trained to work with him/her. P2 heard that neighbors complained about the VA and his/her supervision; however, P2 said that staff persons were “always with [the VA].” · P4 said that when the VA was “agitated,” the VA liked to “be alone.” If the VA was outside smoking a cigarette, staff persons visually supervised through the glass window and if the VA left the property, staff persons immediately went outside and followed the VA. The VA believed that one particular neighbor was his/her “friend” because that person and the VA smoked cigarettes together. Sometimes the VA walked over to that neighbor’s house “almost every day like 10 times.” P4 said that it was possible the VA was without supervision for at most 15-20 seconds before a staff person started following him/her because they had to run back inside to tell the other staff person, who may be cooking or using the bathroom, that they needed to follow in a vehicle. · P5 said the VA “gets far fast” when s/he left the facility property and sometimes the person driving the vehicle caught up to the VA before the staff person on foot. · P6 said that two staff persons always worked with the VA due to his/her aggression and history of leaving without staff person supervision. Staff persons were supposed to have “eyes on” the VA unless s/he was in his/her bedroom or bathroom. If the VA left the property, a staff person was supposed to follow the VA and talk calmly and redirect the VA back to the facility. If the VA entered private property, staff person “try to convince” him/her to return to the facility. Staff persons were not allowed to physically restrain the VA. If the VA was physically aggressive, “blocking pads” were used to protect themselves and the VA. If neighbors said that staff persons were not seen right away, staff persons were likely “giving [the VA] space” by “following behind” the VA and that was okay if they had “eyes on” the VA. P6 was not aware of the VA ever being aggressive towards any neighbors; however, s/he was aware that the VA attempted to involve the neighbors by telling them to call the police. The VA stated that two staff persons at a time worked with him/her and when s/he was outside the staff persons “follow” him/her. When asked about going on to neighbor’s property, the VA admitted that s/he did so and added, “I shouldn’t have done that. I am sorry about that.” The VA said there was one neighbor who was his/her “friend” and that s/he liked to visit that neighbor. The VA thought there might have been a time when s/he walked to the church and no staff persons were present and s/he was issued a trespassing citation. The VA said s/he did not remember some of the incidents this investigator asked about, including running towards a neighbor who was out walking or ringing a neighbor’s doorbell. The CL said that there were concerns that the facility “did not have anything in place” to address the VA’s behaviors despite concerns that the VA repeatedly left the facility and went onto neighbors’ property. The CM was a “targeted mental health case manager” (a role that focused on serving individuals with serious and persistent mental health issues, providing client advocacy, and coordinating access to medical and social services). The CM worked with the VA for “a year and some months” and did not have any information specific to the VA’s supervision requirements other than stating if the VA left the facility, staff persons were supposed to “follow and redirect” and administer a PRN (as needed) medication. The CM said that the VA was not able to accurately report events due to his/her mental health, anxiety, and “low functioning autism.” The G knew the VA for approximately a year and described him/her as “pleasant,” however, s/he was a “handful” and “does things [s/he] should not do.” The VA was “impulsive” and then “remorseful.” The G believed the VA had 2:1 staffing because s/he did “at the other house.” The G said that if the VA left without staff supervision, it “could be” because staff persons were in the bathroom and the VA was aware of opportunities to leave. The G was also aware that the VA was cited for trespassing three times since March 2026. The G was not aware that “blocking pads” were used with the VA until recently. The G said the VA was able to accurately report events because s/he was “honest” and “admitted what [s/he] had done” when prior incidents occurred. Facility documentation showed that prior to the incidents, staff persons were trained regarding the Reporting of Maltreatment of Vulnerable Adults Act. Although during interviews with this investigator staff persons were able to identify the VA’s supervision needs and their responsibilities in providing services to the VA, there was no documentation indicating staff persons were trained regarding the VA’s program plans. The facility stated that a prior staff person did not transfer the training documents appropriately, resulting in a lack of documentation. Subsequent information showed that on May 21 and 22, 2026, (after the incidents) staff persons were retrained regarding the VA’s program plans. Conclusion: Information showed the VA’s history included leaving the facility without staff person supervision. The VA had 2:1 staffing and his/her Elopement Protocol and/or SMA stated if the VA left the property, staff persons were trained to have one person follow the VA on foot and the other followed in a vehicle. On April 26 and 30, 2026, CP1 and/or CP2 believed that the VA was not supervised by staff persons when the VA was in the community; however, no length of time for either incident was provided. Multiple staff persons (P1, P2, P4, P5, and P6) stated there were no occasions when staff persons were not aware of the VA leaving the facility. The VA was described as a “fast walker” and there were times staff persons allowed space between themselves and the VA when the VA was agitated; however, staff persons stated the VA remained within their eyesight when s/he left the property. Although all staff persons denied the VA was ever without supervision, given there was no apparent reason for CP1 and/or CP2 to fabricate what they saw, it was possible that the VA was left unsupervised for a minimal amount of time without CP1 or CP2 seeing the staff persons. Given there was no information that that the VA was harmed as a result of possibly being unsupervised for a minimal amount of time, there was not a preponderance of the evidence whether there was a failure to provide the VA with the supervision necessary to maintain his/her physical or mental health or safety. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate, were followed, and there was no need for additional training for staff persons. The VA no longer resided at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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