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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: 1119996-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) was found deceased in his/her bedroom after staff persons had not seen the VA for more than 10 hours because the VA’s bedroom door was locked. Date of Incident(s): March 8, 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, law enforcement records, and the VA’s autopsy report; and through eight interviews conducted with three facility managers (P1-P3), four facility staff persons (P4-P7), and the VA’s case manager (CM). Although another staff person (P8) was contacted, P8 did not respond to requests to be interviewed. The VA was not subject to guardianship. The VA’s bedroom was on a lower level of the facility as well as a bathroom and a living area. The VA was the only client with a bedroom on the lower level. The VA’s diagnoses included major depressive disorder, post-traumatic stress disorder, arthritis, congestive heart failure, multiple sclerosis, and substance use disorders. The VA enjoyed listening to music, going to parks, and eating “good food.” The VA’s friends and family were important to him/her. The VA’s Rights of Persons Served document stated that the VA had “use of and free access to common areas in the residence and the freedom to come and go from the residence at will,” and the right to privacy including the use of a lock on his/her bedroom door. The VA’s Support Plan Addendum stated that the VA “frequently” refused to take his/her medications because s/he said “they do not help” the VA. Instead, the VA “insist(s) on using street drugs.” The VA wanted to transition out of a community living setting controlled by a provider and to live independently with minimal supervision. The plan had a section titled, “Staff Information/Staff Ratio,” which stated, “Are any additional requirements requested for staff to have or obtain in order to meet the needs of the person? If yes, specify what these requirements are.” “No,” was documented in that section. The VA’s Master Care plan showed that the VA required “regular supervision” and “spot checks” regarding “ongoing supervision and oversight.” The VA’s Intensive Support Self-Management Assessment showed that the VA had a history of refusing to take his/her medications. The VA’s Individual Abuse Prevention Plan showed that the VA needed “regular supervision” and “spot checks” during the overnight shift. However, the frequency of supervision was not documented. The VA’s plans stated the VA needed staff at the facility but did not identify that staff needed to check on the VA at specific intervals. Also, the plans did not identify what actions staff should take when it appeared that the VA was under the influence of substances. The facility had a lease agreement with the VA, which stated that substances, including “drugs” was reason for “an automatic eviction.” The VA initialed and signed the lease on February 27, 2025. Law Enforcement records documented that on March 8, 2026, at 6:17 p.m., officers were dispatched to the facility. Upon arrival, the VA was determined to be deceased in his/her bedroom. P5, who worked with the VA on March 7, 2026, stated that the VA was “good” and that there were no “issues.” P5 also stated that the VA left the facility that day around 2 p.m. and returned around 4 p.m. Although the VA did not tell P5 where s/he went, the VA and P5 “chatted” when the VA returned and P5 did not notice anything out of the ordinary. Shortly after the VA returned, the VA went to his/her bedroom. When it was time for dinner, P5 went to the VA’s bedroom, and the door was closed, which was not unusual. When P5 asked the VA if s/he wanted to eat dinner, the VA declined. P5 did not remember the time, but s/he went down to the VA’s bedroom later that evening and asked the VA, whose door was closed, if s/he was okay and the VA responded, “Yeah.” P8, who also worked the day shift with P5 on March 7, 2026, did not respond to requests to be interviewed. P6 stated that when s/he got to work at 8 p.m. on March 7, 2026, the VA was in his/her bedroom. At about 8:30 p.m., the VA went upstairs to take his/her medication. When P6 stated that s/he needed a little more time to prepare the VA’s medications, the VA went back to his/her room. At about 9 p.m., the VA went back upstairs again and took his/her medications and seemed “fine.” At about 10 p.m., the VA went upstairs again and asked P6 to adjust the thermostat because the VA was “hot.” During the overnight, P6 heard the VA get up to use the lower-level bathroom at least two times, but P6 did not see the VA and did not remember the times that the VA used the bathroom. P6 stated that staff typically checked on clients every two hours, but the VA previously told P6 that s/he did not want people to “disturb [his/her] privacy” and did not want staff to check on the VA during the overnight hours. At times, the VA kept his/her door open, but when the door was closed, the VA always locked the door. Although P6 did not state that s/he checked on the VA during the overnight shift, his/her written statement to the facility stated, “Safety check was done.” On March 8, 2026, P5 began his/her shift after 8:30 a.m. and it was not known whether P6 and P5 communicated about the VA when P5 arrived, before P6 left. P5 provided the following additional information: · On March 8, 2026, P5 arrived for his/her shift and at about 8:30 a.m., P5 went to the VA’s bedroom to administer medications to the VA. When P5 knocked on the VA’s door and called out the VA’s name several times, the VA did not respond. P5 then went upstairs to get a master key to unlock the VA’s door, but the key did not work to unlock the door. At 8:41 a.m., P5 called P2 and stated that s/he had not made contact with the VA and that P5 could not access the VA’s bedroom because the key did not work in the lock. P2 told P5 to keep checking on the VA and reminded P5 that the VA had a history of sleeping late and not responding when staff knocked on the VA’s door. · At 8:45 a.m. P5 went back upstairs and locked the VA’s medication up and then went outside to look in the VA’s bedroom window, which was on the ground floor. Because the VA’s shades were closed, P5 could not see anything. · At 9 a.m., P5 went back to the VA’s bedroom and knocked on the door, but the VA did not respond. At the time, P5 looked underneath the VA’s door to see if s/he could see any movement, but P5 did not see anything. · When P5 still had not had contact with the VA at 11 a.m., P5 called P2 again and left a message. When P5 had not heard back from P2 by 1 p.m., P5 called P3. When P5 told P3 that s/he could not get into the VA’s bedroom, P3 told P5 that s/he would send someone over to see if they could open the door, but a timeframe was not given.
· P5 did not remember the time, but s/he called the VA’s cell phone, while P5 stood outside the VA’s bedroom door. P5 heard the phone ring, but the VA did not answer it. P7, who worked the day shift on March 8, 2026, provided information that was consistent with the information provided by P5. P7 worked with other clients the day of the incident but did not check on the VA because P7 was aware that P5 was periodically checking on the VA and making calls to others when the VA was not responding to P5. P2 said that when P5 called, P5 only stated that the VA had not taken his/her medications, but P5 did not mention that s/he had not been able to contact the VA. P3 said that s/he was aware that the VA “self-medicated” using fentanyl that the VA obtained illegally for pain management and that the VA had unsupervised time in the community. P3 said that P5 called him/her about 2:30 p.m. on March 8, 2026, and stated that s/he did not have verbal or visual contact with the VA that day and that s/he could not get into the VA’s bedroom. P3 told P5 that s/he would call P4. When P3 called P4 and asked him/her to go to the facility to open the VA’s door, P4 said that s/he would but that s/he had other obligations and would go to the facility later. P4 did not remember the time but thought that s/he arrived at the facility between 4:30 and 6 p.m. P4 removed the lock mechanism on the door and when P4 entered the VA’s bedroom, the VA was sitting on a chair, and his/her head was leaning on a table in front of the VA. P4 saw that the VA was deceased, the VA did not have a pulse and was not breathing. P4 told staff to call 9-1-1 because the VA was “gone.” The law enforcement report stated that law enforcement was called at 6:17 p.m. on March 8, 2026, and that officers arrived at the facility at 6:34 p.m. The VA had “obvious signs of rigor mortis setting in.” A “white powdery substance,” and a “piece of burned tinfoil” were found in the VA’s bedroom. A law enforcement officer stated that when substances were found, they sent those substances to the Bureau of Criminal Apprehension for identification. The VA’s Autopsy Report showed that the VA’s cause of death was “mixed cocaine, fentanyl, and methamphetamine intoxication.” The report did not provide an approximate time of death. P1 provided the following information: · P5 and P8 worked from 8 a.m. until 8 p.m. on March 7, 2026, P6 worked from 8 p.m. on March 7, 2026, until 8 a.m. on March 8, 2026, and P5 and P7 worked from 8 a.m. until 8 p.m. on March 8, 2026. When P1 talked to those staff persons, after the incident, about how the VA was doing in the days before his/her death, P1 heard that the VA had “episodes of up and down,” which were typical of the VA, but no significant concerns were raised. The VA wanted privacy, and it was not unusual for the VA to not respond when staff knocked on his/her bedroom door. P1 also learned that the VA changed the lock on his/her bedroom door without staff knowledge. P1 was not aware of a previous time that the VA changed the lock on his/her bedroom without staff knowledge. · The VA, who had a history of substance use, such as fentanyl, had unlimited unsupervised time in the community. Staff were expected to check on clients every two hours to ensure safety, but the VA told P1 that s/he did not want staff to check on the VA when the VA was in his/her bedroom. · When the VA used fentanyl in the community and then returned to the facility, there were times that the VA was “basically unresponsive” for periods up to three days. When this happened, the VA would only “mumble” responses to staff, got up to do “basic things,” like eat or use the bathroom. Staff could see “eye movement” when staff talked to the VA. When this happened, staff checked on the VA periodically. · Prior to the incident, the facility was in the process of evicting the VA, partly because the VA was not paying scheduled rent, engaging in excessive property destruction, and not complying with the facility’s policy to not use substances on the property. However, legal issues prevented the facility from following through with evicting the VA. P3, P5, and P6 also said that it was not unusual for the VA to sleep late and not respond when staff knocked on the VA’s bedroom door. The CM stated that the VA had unlimited unsupervised time in the community. The CM also stated that s/he did not have concerns related to staff supervision and that s/he had several discussions with the VA to refrain from using substances in the community and within the facility. The facility’s Internal Death Review stated that “day staff followed required supervision protocols,” and “attempted multiple checks, reported to on-call supervisors, documented their efforts, and escalated concerns appropriately.” The review also determined that “overnight documentation [by P6] lacked required detail regarding welfare checks.” The facility’s Program Abuse Prevention Plan stated that “supervision will be provided according to the needs of each resident,” and that “staff will be in audio range and check on residents being served frequently.” P1 said that the word regularly was not defined, but that it had been discussed at staff meetings prior to the VA’s death. The VA’s Resident Notes, written by P6, provided information that was consistent with the information P6 provided in his/her interview with this investigator. The note for March 8, 2026, staid that “safety check was done.” P6 was no longer employed by the facility. Prior to the incident, the facility did not have a policy that specified the frequency of client checks and no documented policy that stated clients were to be checked on every two hours. After the incident, the facility created a Policy and Procedures/Wellness Check, which stated, “To ensure residents receive consistent monitoring and support while maintaining dignity, independence, and quality of life in a safe environment,” staff were to “conduct wellness checks on all residents at least every two hours, unless otherwise specified in the residents individualized service plan,” and that the checks could include “visual observation of the resident” and “confirmation of safety and well-being.” The document also stated that “overnight checks will be completed in a manner that minimizes sleep disruption while ensuring resident safety.” The facility’s training records showed that all staff interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s care plans prior to March 8, 2026. Conclusion: A. Maltreatment: P6 stated that at about 10 p.m. on March 7, 2026, the VA went out of his/her bedroom and asked P6 to adjust the thermostat then returned to his/her bedroom. P6 heard the VA use the lower-level bathroom at least two times during the overnight, but P6 did not see the VA. P6 documented that safety checks were completed. P5 stated that at about 8:30 a.m. on March 8, 2026, s/he went to the VA’s bedroom to administer medications to the VA, the VA did not respond when P5 knocked on the VA’s door and called out his/her name several times. P5 tried to use a master key to gain access to the VA’s bedroom but was not successful. P1 stated that the VA changed his/her bedroom door lock without telling staff persons. At 8:41 a.m., P5 called P2. P2 told P5 to keep checking on the VA and reminded P5 that the VA had a history of sleeping late and not responding. When P5 continued attempting to contact the VA, without success, P5 called P2 again around 11 a.m. and left a message. When P5 had not heard back from P2 by 1 p.m., P5 called P3. P3 called P4 and asked him/her to go the facility. When P4 arrived at the facility, between 4:30 and 6 p.m., P4 gained access to the VA’s bedroom by removing the lock and found the VA without a pulse and not breathing. The VA was deceased. P4 told staff to call 9-1-1. When law enforcement arrived at the facility at 6:34 p.m., the VA had “obvious signs of rigor mortis setting in.” The VA’s Autopsy Report showed that the VA’s cause of death was “mixed cocaine, fentanyl, and methamphetamine intoxication.” Although the VA’s plans did not specify how often the VA needed to be checked on by staff persons, given that the VA had a known history of obtaining and using fentanyl, and that it took 10 hours after P5 was unable to get into the VA’s room to discover the VA deceased including conversations with supervisors which was not reasonable given the VA’s history, there was a preponderance of evidence that there was a failure to provide the VA with reasonable and necessary care and 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. Facility staff persons at multiple levels of authority knew P5 could not get a response from the VA who had a history of substance use, including fentanyl. It took 10 hours to get into the VA’s bedroom from the time P5 realized the VA was not responding. In addition, the facility did not have a plan in place for staff persons to adequately supervise and monitor the VA given the VA’s history of substance use and did not specify in the VA’s plans how staff persons were to supervise and check on the VA. Given that P6 heard the VA overnight twice and documented safety checks were completed, and P5 continued to act including calling two supervisors and checking through the VA’s window, staff persons’ responsibility was mitigated. Therefore, because of inadequate policies and plans and that staff persons at multiple levels knew the VA was not responding to P5 yet it took 10 hours to get into the VA’s bedroom, the facility was responsible for the maltreatment 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 because it was not able to be determined whether finding the VA earlier would have prevented the VA’s death. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate, not followed by P6, and that additional training was needed. In addition, the review stated that “supervisors will conduct unannounced overnight spot checks,” and “staff will receive additional training on identifying relapse indicators and overdose risk.” Action Taken by Department of Human Services, Office of Inspector General: On August 4, 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.
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