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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: 1071982-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA), who had previous incidents of threatening facility staff persons with knives, stabbed a staff person (P8) in the abdomen with a knife and subsequently the VA was arrested. Previous incidents of the VA threatening staff persons with knives were documented and discussed with facility supervisors but no action was taken. Date of Incident(s): March 26, 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 16, 2026; from documentation at the facility, and law enforcement records; and through eight interviews conducted with the VA, three facility staff persons (P1, P6, and P7), three facility supervisors (P2, P3, and P5), and the VA’s guardian (G) who was also a family member. Requests to interview P4 and P8 via phone and United States mail were unsuccessful, but both provided information to the facility for the Internal Review which was included below. The VA was diagnosed with schizoaffective disorder. The VA enjoyed listening to music, playing video games, sports, driving in his/her car, and spending time with family. According to the VA’s plans, s/he had unlimited unsupervised time at the facility and in the community. The VA had his/her own vehicle, a driver’s license, and delivered food in the community as a means of employment. At the time of the incident, the VA lived at the facility with three other clients and the VA “loved” living there. The VA’s plans stated that it was important for the VA to have “consistent and familiar” staff persons. Precursors that “interfering behaviors” were more likely to occur after the VA drank alcohol included being out of his/her bedroom with minimal clothing or making comments that “crossed a boundary” with staff persons. The “voices” that the VA heard might tell the VA to do things that were “not safe or in [the VA’s] best interest.” The VA’s plans did not show a history of violence or aggression toward others and there were no limitations in the VA’s plans preventing the VA from having access to sharp objects unless the VA was “visibly intoxicated.” If the VA was intoxicated, sharp objects, medications, or any harmful materials were to be removed from the VA’s reach. (Investigator’s note: there was no information that the VA was “visibly intoxicated” at the time of the incident.) The facility had a main and lower level. The kitchen was on the main floor. At the time of the incident, a knife block with assorted knives was on a counter in the kitchen next to a microwave. Law enforcement records and information from P1 showed that on March 26, 2026, at approximately 6:55 p.m., P1 called 9-1-1 to report that the VA stabbed P8 with a knife. The VA stated s/he took the knife from the kitchen a couple of minutes before the incident. The VA had not previously planned to use the knife on P8, but it “just happened” because the VA did not like P8 and “kind of got mad at” P8. The VA stated that on two previous dates, the VA “joked” with a couple of staff persons while using knives. The VA stated s/he was “fucking with” the staff persons and insisted that it was “all jokes.” The VA estimated this was around Christmas 2025, and that staff persons told the VA not to do that again. The VA felt bad because s/he was not trying to “hurt their feelings.” The VA did not provide any more information about the incidents and ended the interview. P1 provided the following information: · On March 26, 2026, P1 and P8 were working together at the facility and it was a “normal” day. At around 6:10 p.m., after eating dinner, P1, P8, and several of the clients were in the living room watching TV. One client was taking a nap and the VA was pacing around the main floor, which was “normal” for the VA. P1 went to the lower level at one point, returned upstairs and entered the kitchen. In the kitchen, P1 passed the VA, who was at a sink getting some water. P1 asked the VA how s/he was doing and at first, the VA did not respond, but then said s/he was “fine.” P1 returned to the living room. · At around 6:20 or 6:30 p.m., the VA said, “Hey [P8].” This struck P1 as “weird” because the VA typically called out for P1 when P1 and P8 were working. P8 was a newer staff person and the VA did not “open up” to newer staff persons as well. P8 went to the kitchen and returned to the living room several seconds later. P1 did not hear anything and P8 told P1 that the VA did not want anything. The VA continued to pace the main floor in a pattern; behind the chair P1 was sitting in, to the front door, to the VA’s room, and back several times. · About 15-20 minutes later, the VA again called P8, and said, “Come here.” P8 got up right away and went to see what the VA wanted. P1 next heard P8 “yelp” as P8 jumped backward from the VA, while holding his/her hand over his/her own stomach. P1 initially thought that the VA “spooked” P8, but then P8 said, “[The VA] stabbed me twice.” · P1 got all clients, except the one who had been sleeping through the incident, and P8 out of the facility. P1 called 9-1-1 using P8’s phone because P1 left his/her phone inside the facility. · Emergency medical services (EMS) and law enforcement officers (LEOs) arrived at the facility, LEOs got the other client out of the facility, and began looking for the VA, who was not inside the facility. EMS treated then transported P8 to a local hospital. According to P8, via the facility’s Internal Review, after the VA called P8 the first time, the VA responded, “Never mind.” The second time, about 20 minutes later, the VA said nothing and just “came at” P8. P1, P2, P3, and P5 provided the following information: · P2, P3, P4, and P5, all supervisory staff persons were notified of the incident and shortly after, P3, P4, and P5 arrived at the facility. · The VA went back to the facility twice throughout the next several hours. The first time, P5 saw the VA back his/her car out of the facility driveway. The next time, P5 stated s/he saw the VA through the side door glass at the top of the basement stairs. P5 told the VA through the glass door that s/he could not let him/her back inside the facility. P5 stated that the VA “put [his/her] head down,” and appeared “confused, scared, [and] guilty,” and then drove away in his/her car. The G stated that on March 26, 2026, the VA arrived at the G’s house and was “detained safely” by LEOs. In the days leading up to the incident, P1 stated that the VA had been “completely silent.” P1 told staff persons to keep an eye on the VA the night before the incident because the VA had been acting “kinda weird.” P8 said, via the Internal Review, that on March 25, 2026, the VA was quieter and did not verbally respond much. When the VA did respond, s/he was “mumbling.” P7 stated that the VA was “acting different[ly]” leading up to the March 26, 2026, incident. P5 stated s/he saw the VA on March 25, 2026, and the VA was “kind of abrasive” in a way that P5 had not seen before. According to P5, on the morning of March 26, 2026, P5 asked P6 how the VA was doing and at that time, P6 said that the VA was acting “normal.” P6 stated that for the week prior to March 26, 2026, the VA was acting “off,” and was “pacing” more than usual. P6 said that after talking to P5, but before the incident, on March 26, 2026, the VA told P6, “I’m gonna fuck you up,” and smiled, then giggled. According to the Internal Review, a community mental health professional arrived on March 26, 2026, prior to the incident to meet with the VA. His/her notes indicated that staff persons were concerned about the VA and his/her “behaviors,” such as laughing to him/herself or playing “tag” with him/herself. Recently, the VA had been sitting in a chair, staring out the window, talking to him/herself, and alternating between “isolation and overt behaviors.” The G stated that s/he was not aware that the VA had been “acting bizarre.” The VA had “delusions” all the time, “heard voices” at his/her “baseline,” and had a type of schizophrenia that was “medication resistant.” Facility documentation, interviews, and the facility’s Internal Review showed that prior to the incident on March 26, 2026, there were incidents of the VA holding knives and making statements toward staff persons: · P3 stated that when s/he arrived at the facility on March 26, 2026, s/he learned that there had been previous incidents involving the VA and knives documented and reported to P4, but that P4 did not relay the information to P2 or anyone within the quality assurance unit. · P2 stated that when s/he arrived at the facility on March 26, 2026, P3 told P2 about the previously documented incidents of the VA “joking” about knives with staff persons on two or three prior dates, specifically toward P1. · After the March 26, 2026, incident, P5 learned of incidents prior to January 2026. P5 did not read the prior shift notes where the prior incidents were documented and said that it was not P5’s responsibility to review the shift notes, but to ensure that the notes were being written by staff persons. P5 did not recall the incidents being brought up at any staff meetings that s/he attended but thought that the facility should have been able to get a rights restriction to “lock up” the knives. If P5 had known about the prior incidents, s/he would have “pushed harder” to get a rights restriction. With P4 no longer working at the facility, P5 found that P4 did not always follow through on things that s/he said she was going to do. · On September 5, 2025, P1 documented in a progress note, “[The VA] went in the kitchen and came back with a large knife and held it towards [P1] and said, ‘Give me my med[ications] now or else,’ while laughing. [P1] told [the VA], ‘That’s not funny, please don’t do that.’ [The VA] laughed and said [s/he] was just kidding.” · On October 11, 2025, P1 wrote in a progress note, “[P1] went to the kitchen to unload the dishwasher. [The VA] took a cooking knife from the knife block and held it in a stabbing motion and directed the motion of stabbing towards [P1]. [P1] told [the VA], ‘What are you doing? Please do not stab me.’ [The VA] said, ‘Sorry buddy, I was just kidding.’ [P1] told [the VA], ‘I don’t think that stabbing me would be a very funny joke.’ [The VA] said, ‘I know buddy, I’m sorry.’” · On January 18, 2026, P1 wrote in a progress note, “[The VA] came out of [his/her] room . . . asked [P1] if they stole a tater tot off [the VA’s] plate. [P1] told [the VA], ‘No.’ [The VA] then pulled a kitchen knife out on [P1] and asked the same question. [P1] sternly told [the VA] not to joke around like that and [the VA] told [P1] that [s/he] was sorry and [s/he] was just joking. [P1] told [the VA] that ‘that is not funny.’” · P5 stated that after the incident on January 18, 2026, P1 told P5 that the VA threatened to stab P1, and held a knife near P1’s stomach. P5 told P4 about the incident. P4 replied that it was “really hard” to get a rights restriction, but that P4 would talk to P2 about it. P5 never heard any further update from P4, but thought that P4 let P2 know. · P4 confirmed, via the facility’s Internal Review that s/he was aware of the January 18, 2026, incident, and that the VA was “joking around.” P4 said that s/he did not remember which staff person brought up the January 18, 2026, incident and that s/he “talked to [P2] for a brief minute then [s/he] got a phone call.” · P1 stated that at a staff person meeting, possibly the February 2026, meeting, and possibly another time, s/he brought up the history of the VA grabbing knives. P1 said that at the meeting, P6 shared similar experiences regarding the VA making jokes about/with knives. P1 stated that s/he was not scared of the VA during these incidents but was serious in letting the VA know that it was not a joke. According to P1 and P7, at some point after the meeting, P4 or P5 responded that the facility would need a “rights restriction” in order to remove the VA’s access to the kitchen knives. P4 or P5 told staff persons to not “play into” the VA’s jokes and to remind the VA that it was “not appropriate.” P7 provided information consistent with P1 and that P4 or P5 told staff persons that removing knives or sharps were a “rights restriction” and to redirect the VA and remind him/her that threats were not a joke. · P6 stated that s/he knew s/he told P4, who was at the facility more than P5, but “could have” told P5 outside of staff meetings about the prior knife incidents. P6 stated that when P1 and P6 asked about getting the knives locked up or put away, P5 told P6 that P4 said that rights restrictions were very hard to get. This was reiterated by P4 at staff meetings. P6 denied notifying P2 of the knife incidents but was told by P4 that P4 was notifying P2 of everything that was discussed at staff meetings. P6 said that the incidents were discussed at one or more of the January, February, or March 2026, staff meetings by both P1 and P6. · According to P6, during the prior knife incidents with the VA, the VA had different knives for different incidents. P6 documented every incident when the VA used knives, which P6 stated was “three to four times” with P6 and “four to five times” with P1. P6 said that s/he told P4 and P5 every time that the VA “displayed” a knife. (Investigator’s note: There were no incidents documented by P6 about the VA using knives in the documentation from the facility.) · P6 said s/he typically told the VA that it was “super serious” that s/he used the knife and told him/her to put it away, one of those times being when the VA pulled out a knife toward P1. P6 said that the VA always “felt bad” getting “called out” and would say that s/he was “joking” and would not do it again. · After the March 26, 2026, incident, P2 was unable to locate any of the meeting minutes where the knives had been discussed. · P7 stated that s/he heard that the VA “made threats” with a knife to P1 and P6, but P7 had not witnessed threats. · P8, via the Internal Review, stated that P8 had not worked at the facility for very long and that there were no previous threats by the VA, nor had s/he been aware of previous incidents regarding the VA or any knife incidents. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Relevant Minnesota Rules and/or Statutes Minnesota Statutes, section 245D.081, subdivision 1 stated that the license holder was responsible for coordination of service delivery and evaluation for each person served by the program and program management and oversight that included evaluation of the program quality and program improvement for services provided by the license holder. Conclusion: Information was consistent that on March 26, 2026, the VA stabbed P8 with a knife at the facility. P1 and P8 stated that the VA called P8 twice, twenty minutes apart, the first time saying, “never mind,” and the second time, when P8 went to the VA, the VA stabbed P8 in the abdomen. LEO and EMS arrived and transported P8 to a hospital. The VA was arrested later that night by LEOs. The VA stated that s/he had not planned to use the knife on P8 but it “just happened.” On September 5, and October 11, 2025, and January 18, 2026, there were documented incidents of the VA holding a knife toward staff persons making comments about using the knife. Staff persons told the VA to not do that and each time, the VA stated s/he was kidding or joking and did not harm staff. P6 stated s/he documented additional similar incidents, but the facility did not have that documentation. P1, P6, and P7, stated that the previous knife incidents were discussed at one or more of the January, February, or March 2026, staff meetings and that P4 or P5 stated that rights restrictions were hard to obtain and no action was taken. P4 and P5 stated that they were aware of the January 18, 2026, incident but P5 stated s/he was not aware of incident prior to that because s/he did not review shift notes where the incidents were documented. P5 said that when s/he talked to P4 about the January 18, 2026, incident, P4 told P5 that rights restrictions were “really hard” to obtain. P4 told P5 that s/he would talk to P2 about it, but P5 never heard anything further. P4 said that s/he started to talk to P2 about the incident but was interrupted. P2 and P3 did not know of any prior incidents until after the March 26, 2026, incident. P2 was unable to locate meeting minutes for staff person meetings at the facility. Documentation of the incidents and discussions regarding the incidents was incomplete, knowledge about the incidents among facility supervisors varied so there was no action taken such as reevaluating the VA’s risks and needs, and the shift notes were not reviewed by a facility designated manager or designated coordinator at the time the incidents occurred, which was in violation of Minnesota Statutes, section 245D.081, subdivision 1. Although the VA stabbed P8 with a knife resulting in the VA being arrested, and the VA had taken out knives and put them toward staff persons in the past, given that the VA stated s/he was joking or kidding during past incidents, that the VA did not harm staff persons during previous incidents or have a history of harming others, and that the VA did not have restrictions for having access to knives, there was not a preponderance of the evidence whether there was a failure to provide the VA with reasonable and necessary care and services. 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’s Internal Review showed that policies and procedures were adequate but not followed. P5 was retrained and P4 no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: On August 3, 2026, the facility was issued a Correction Order for the violation outlined in this report.
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