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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: 1072890-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Lindsay Arth Lindsay.Arth@state.mn.us Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) died by suicide. There were concerns that facility staff persons did not sufficiently address the VA’s mental health symptoms and did not adequately supervise the VA. Date of Incident(s): August 4, 2025, and prior 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 August 28, 2025; from documentation at the facility, law enforcement records, and medical records; and through eight interviews conducted with three facility supervisory staff persons (P1, P2, and P5), two staff persons (P3 and P4), the VA’s case manager (CM), the VA’s mental health case manager (MHCM), and the VA’s family member (FM). Attempts were made via phone call and email to contact P4 and P5 for follow-up information but P4 and P5 did not respond. The facility was in a duplex and next to the facility was a different program operated by the same license holder. There were four clients on each side. The VA’s side had two floors and the upper floor was the VA’s bedroom, another client’s room, a living room, and kitchen. Off the kitchen was access to a deck, a fenced in backyard, and a wooded area. The facility had asleep overnight staff persons. The VA’s diagnoses included schizophrenia and bipolar affective disorder. The VA was not subject to guardianship. The VA moved into the facility on June 20, 2024, and passed away on August 4, 2025. The VA enjoyed working out, playing video games, and being outside. The VA’s Arrowhead House East Intensive Residential Treatment Services Functional Assessment dated March 6, 2024, said that the VA “struggled to maintain relationships and appeared to “self-isolate,” including in his/her bedroom to play video games by him/herself. The VA attempted “self-harm” due to “command hallucinations.” The VA “recently verbalized” that s/he was “being commanded to end [his/her] life.” The VA received psychiatric medication management through WebMED. The VA had a history of eloping from “treatment” and appeared to be at risk of stopping his/her medication and experience psychiatric decline. The VA “lacked insight” into his/her mental health concerns and appeared at risk to disengage with services if “not legally mandated to.” (Note: This documentation was provided to this investigator from the facility but was from the program the VA lived immediately prior to the VA living at the facility.) The VA’s Individual Abuse Prevention Plan dated June 10, 2025, said that the VA had a history of threatening to “hang” him/herself. The VA could be “difficult” to get information from, including “opening up about [his/her] symptoms” but the VA may notify the FM about these things. Staff persons were to “touch base” with the VA a “minimum of every hour” to see how the VA was doing and try to talk to the VA about “any symptoms” s/he may be having. Staff persons were to “question” the VA about what may be going on to “get a better of idea” of how they could help him/her. Staff persons were to also “attempt to engage” with the VA approximately every hour to see if there was “anything they could do” for the VA. The VA was able to be unsupervised in the community but did not always let staff persons know where s/he was going. (Note: There was nothing noted in the VA’s plans regarding how long the VA could be unsupervised in the community. P1 stated that the VA had four hours of unsupervised time in the community that was discussed at the VA’s 45-day meeting and implemented by staff persons, but that it was not noted in the VA’s plans, which was a violation of Minnesota Statutes section 245A.65, subdivision 2, paragraph (b), which states in part that the individual abuse prevention plan shall include a statement of measures that will be taken to minimize the risk of abuse and shall be developed for each new person as part of the initial individual program plan or service plan.) The VA required “some assistance and/or supervision making and keeping medical appointments.” Staff persons were to “hand” the VA his/her medications. The VA’s Intensive Support Self-Management Assessment dated June 13, 2025, said that the VA could independently take his/her medications when handed them. The VA was “willing” to go to all provider appointments and did not need “supports” in this area. However, if the VA was not taking his/her medications as prescribed, s/he may refuse to go to appointments or make “strange or paranoid statements” including to the FM. The VA’s Individual Resident Placement Agreement dated June 10, 2025, provided the following information: · The VA was to “go to” staff persons when s/he felt anxious or had “symptoms.” Staff persons “could not help” the VA if the VA “did not talk to them about what was going on.” Staff persons were to also do hourly check-ins with the VA and if the VA felt anxious, they were to discuss taking an as needed (PRN) medication for anxiety with the VA. · The VA had a history of “struggling” with hygiene when “symptomatic” but in 2025, there were “no concerns” with the VA’s hygiene. The VA also had a history of refusing medications so staff persons were to “cue” the VA when s/he needed to take his/her medications. As of 2025 (no month noted), there were two incidents when the facility did not receive the VA’s medications from the pharmacy due to needing a refill from the VA’s provider but staff persons were able to get them refilled “right away.” · The VA “struggled” remembering dates and times for appointments, so staff persons assisted the VA with reminders and transportation was provided to “all provider appointments and activities.” The VA was starting therapy sessions with a provider “hopefully soon.” · The facility offered activities for the clients to participate in and the VA was to let staff persons know things s/he would like to do. · The facility was to ensure that clients were offered three meals and three snacks a day. Typically, clients made their own breakfast and lunch but staff persons were to offer to help the VA make something for breakfast and lunch. (Note: Staff persons made dinners). The VA’s Mental Health Support, Relapse Prevention, and Crisis Plan dated June 13, 2025, said that if staff persons noticed that the VA was in his/her bedroom “a lot,” they were to talk to the VA, offer the VA an activity, or “anything to try” to get the VA more active. If the VA was “acting strange,” they were to take the VA to the hospital and notify the VA’s case manager. The VA’s medication administration record (MAR) showed that the VA was prescribed one medication, paliperidone (Invega) (used to treat schizophrenia), by mouth at bedtime. Documentation showed that this medication was administered in June, July, and August 2025, with the exceptions of June 1, 9, and 10, 2025, when the VA was “out,” and on June 6 and 18 and July 3, 6, and 23, 2025, when the VA refused. Additionally, on June 16, 2025, there was no documentation that noted the VA’s medication administration, which was a violation of Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), which states that the license holder must ensure that any occurrence of a dose of medication not administered as prescribed be documented in a person’s medication administration record. The VA’s Care Notes dated July 23, 2025, around 3:45 p.m., P2 documented that the VA asked him/her how s/he could “stop” his/her medications. P2 asked the VA why s/he wanted to stop them and the VA stated that s/he “felt better” and did not need them anymore. P2 told the VA that s/he needed to “consult” with his/her doctor before discontinuing any medications and the VA said, “Okay.” The VA then returned to his/her bedroom and made an unknown phone call. On August 4, 2025, P4 worked at the facility from 10 a.m. to 2 p.m. At 2 p.m., P3 arrived. P5 worked on both sides of the facility from 7 a.m. to 5 p.m. The law enforcement Case Report Summary provided the following information: · On August 4, 2025, at 2:46 p.m., law enforcement was notified by a facility neighbor (N), that the VA was in the facility backyard and appeared deceased. The N could not get “over the fence” and was trying to notify staff persons. The N saw that the VA’s arm was blue and s/he did not know how long the VA had been there. · When law enforcement arrived at the facility, they were met by P5 and the N who walked with them to the VA. When law enforcement saw the VA, they “confirmed” that the VA was deceased. · Law enforcement spoke to P5 who said that the VA had recently stopped taking his/her medications and “attempts” were made by P5 to speak to the VA’s doctors about this but that the VA refused to attend the appointments. P5 also said that staff persons drove the VA to appointments and remained there so that they could “confirm” that the VA attended the appointments. P5 was not aware of the VA having thoughts to self-harm. · An unidentified person told law enforcement that the VA was “possibly” last seen by a staff person (P6) on August 3, 2025, at 8 p.m.
· Law enforcement searched the VA’s phone and saw that at an unidentified time on the morning of August 4, 2025, the VA searched information on his/her phone regarding how to harm him/herself. The FM provided the following information: · The FM had concerns that staff persons did not know where the VA was and that the N found the VA deceased. The FM read in the police report that the VA had not been seen for 14 hours prior to being found by the N and that the VA was last seen the day prior at 8 p.m. for his/her medication and “no one saw [the VA] after.” · Approximately once a month, the FM or another family member visited the VA. July 4, 2025, was the last time the FM saw the VA, and the VA was his/her “normal” self which the FM described as “Eeyore.” [Note: Eeyore was a character from Winnie the Pook who was generally characterized as pessimistic and depressed, and had reduced motivation and/or ability to experience pleasure.] At that time, the VA had a “psychiatric meltdown” in the FM’s car and said that s/he was “too hot” so the FM “had to pull over.” · The “Sunday” before the VA’s death (August 3, 2025), another family member saw the VA and that family member said that the VA was “fine.” · The VA would not have told any staff person about his/her intent to harm because the VA “did not trust anyone” and would “deny” when asked about it. · The FM had concerns that the facility was not “refilling” the VA’s medication and “let it run out.” The VA also went for a “long time” without his/her medications. The FM provided an example of this and said that the VA came to the FM’s home for Christmas in 2024, and the facility sent the VA with “one pill” despite it being a three-day visit. In July 2025, the VA had a “psychiatric meltdown” which made the FM think that the VA was not taking his/her medications. The VA was not “capable” of taking medications on his/her own and the facility “knew that” because the FM “told them.” The facility should have notified the FM if the VA was not taking his/her medications and taken the VA to his/her psychiatrist appointments so that the VA saw a “professional.” The VA was to see a psychiatrist once a month to be “checked on,” because of the medications s/he was prescribed but P1 told the FM that the VA had not seen “anyone” for six months and that staff persons would “just drop” the VA off and the VA would not attend the appointments. The FM told the facility that they should not drop the VA off because the VA had “anosognosia” (a condition where your brain cannot recognize one or more health conditions and was common with conditions such as schizophrenia). · For the prior two years, the VA was “depressed and struggling,” “always hearing voices,” and would “hardly sleep.” The FM knew this because staff persons “complained” that the VA took food from the other licensed program during the night. · The FM said that the VA “slipped through the cracks” and believed that the facility “did not do their job at all.” P5 provided the following information: · On August 4, 2025, at 6:45 a.m., P5 arrived at the facility for his/her scheduled shift and did his/her typical supervisory duties which included paperwork in his/her office, which was on the other side of the facility, and talking to the clients on that side. P4 worked on the VA’s side until 2 p.m. and at 2 p.m., P3 began working on the VA’s side. P5 did not see the VA that day which was normal for the mornings. Staff persons were not trained to check on the VA at any specific time but staff persons typically saw the clients, including the VA, at some point during their shift. · At 2:30 p.m., P5 was in his/her office when s/he heard an unknown voice outside the front of the facility yelling that someone was “hanging.” P5 ran outside to the front of the facility, saw an unknown neighbor, and asked him/her, “What’s going on?” The unknown neighbor said, “[S/he’s] hanging” and that s/he was on the phone with 9-1-1. P5 then went towards the backyard and saw the VA deceased. P5 was “emergency medical responder” trained and once P5 reached the VA, s/he did a “tap and shout,” sternum rub, and felt for a pulse but did not find one. Due to P5’s experience, s/he realized that the VA was deceased. The VA’s right leg and hands were purple but everything else was “pale.” P5 left the VA as s/he found him/her and then ran inside and “yelled” for P3 that the VA was deceased and told P3 to ensure that no clients went to the backyard. P3 did so and then came outside where s/he and P5 waited for law enforcement to arrive. · P5 said that “days” after the incident, staff persons including P5, talked to the clients including (C3), who lived on the other side of the facility from the VA. C3 said that s/he last saw the VA at 7:30 a.m. that morning when the VA “walked by” him/her. C3 did not have any concerns with the VA at that time. · P5 said that “days” after the incident, P1 told P5 that after the incident, once P1 notified the FM that the VA was deceased, the FM told P1 that the VA mentioned to the FM about getting a “rope” but P5 had not heard that prior. P5 was not aware of any prior concerns with the VA, including suicidal attempts, and the FM never mentioned any concerns to staff persons. The VA did not have any prior “signs” that the VA was going to harm him/herself. · P5 did not know who the VA would tell if s/he had mental health concerns but, some “signs” would be that the VA would say that s/he did not want to take his/her medications which occurred at some point prior to the incident (likely the end of July) and staff persons told the VA to talk to his/her doctor. The VA then spoke to his/her doctor and told staff persons, “I guess I need to stay on them.” Following the incident, P5 looked at the VA’s medications and saw that the VA took his/her medications as prescribed, including the night prior. The VA also had as needed (PRN) medications but “never utilized them.” P5 believed the VA was taking his/her medications as prescribed. Staff persons were trained to administer clients medications by handing the clients their medications and watching them take them, which staff persons were doing. · The VA only took medications at night so there was no scheduled times for staff persons to wake the VA. However, staff persons typically knocked on the VA’s door if they made lunch. P5 did not know what time the VA passed away and said that where the VA was found in the backyard was not easily seen from inside the facility or from the front yard. · At times, P5 drove the VA to various places including stores, a movie theatre, or “downtown” and would “drop” the VA off. The VA could also go on a walk or leave the facility as s/he desired and was supposed to “sign out” but “never” did. The VA was typically a “homebody” and wanted to remain at the facility playing video games. The VA could also be in the facility yard but was not normally in the part of the backyard where s/he was found. · The VA could attend medical appointments independently. Staff persons took the VA to medical appointments and got the VA “checked in.” Staff persons then returned to the facility van and “sit” and wait for the VA to call and say s/he was “done.” At times, depending on other client needs or the length of the VA’s appointment, staff persons dropped the VA off and the VA would call once the appointment was completed and staff persons then picked the VA up and drive the VA back to the facility. At some point, P5 found that sometimes the VA left without attending the appointment. When staff persons discovered that the VA was not attending appointments, a facility supervisor took the VA or ensured that the VA’s appointment was scheduled. The FM also took the VA to a “couple [appointments].” · Staff persons were trained annually on suicide prevention and mental health, and P5 felt well trained. P3 provided the following information: · P3 did not recall the date of the incident, but on that date, P3 arrived at the facility at 2 p.m. P3 spoke to P4 and P5 who were downstairs and then went upstairs and saw two clients (C1 and C2) on the couch. The VA’s bedroom door was open so P3 went to see if the VA was sleeping, which was typical for the VA, but C1 told P3 that the VA was asleep so P3 did not check on the VA. P3, C1, and C2 then had a conversation for approximately 30 minutes and then they went outside to smoke in the front yard. Shortly after, P3 heard P5 calling P3’s name to come to the backyard and to make sure the clients did not come. P3 then went to the backyard and saw the VA as previously described. P3 was going to take the VA down but P5 told P3 that s/he checked the VA’s pulse and the VA was deceased. P5 told P3 to remain outside with him/her in the backyard until law enforcement arrived. · P3 last worked with the VA the prior Friday and Saturday (August 1 and 2, 2025), and the VA was in an “upbeat mood.” P3 spoke to the VA for an “hour or two” and cut the VA’s hair. P3 asked the VA how s/he was doing and the VA said, “Fine.” P3 had no concerns at that time and the VA did not mention thoughts of harming him/herself. On August 2, 2025, around 2 a.m., the VA left the facility during the overnight shift. P3 learned of this because when P3 left the facility that morning, his/her Lyft driver told P3 that at 1:46 a.m., s/he picked up the VA and took the VA to a gas station to get a cigar and that the VA wanted to go somewhere else but the VA did not have “enough money.” The Lyft driver brought the VA back to the facility at 2:15 a.m. Staff persons slept during the overnight on the couch outside the VA’s bedroom door but P3 did not hear the VA leave and the VA was in his/her room when P3 awoke at 6 a.m. P3 was not aware of any other times that the VA left the facility during the night. · The VA could be unsupervised in the community and there were no scheduled checks on the VA while s/he was at the facility. However, P3 typically “checked on” the clients when s/he arrived at the facility. · At the time of the incident, P3 was not aware of any changes in the VA’s life, was not aware of the VA having any changes in his/her typical demeanor, and was not aware of any prior attempts of the VA trying to harm him/herself. The only person who the VA “confided” in was the FM. When P3 asked the VA how s/he was doing, it was “always fine.” The VA typically remained in his/her bedroom to play video games or sleep. At times, the VA came out to watch TV or play games with staff persons. P3 described the VA as “one for a few words.” · At some point prior to the incident, the VA wanted to get off his/her medications but the VA saw a doctor who said that the VA needed to remain on his/her medications. P3 administered the VA’s 8 p.m. medication, which was the only medication the VA was prescribed, and P3 watched the VA take them. P3 never took the VA to medical appointments so P3 did not know if staff persons went into the appointments with the VA. · P3 was trained on the client’s plans including mental health and also said that there was a crisis phone number staff persons had available to them if needed. P4 provided the following information: · On August 4, 2025, at 9:45 a.m., P4 arrived to the facility for his/her scheduled shift. At that time, C2 was outside and asked to go to the store so P4 drove C2 to the store. When P4 returned, P5 asked P4 to go to the grocery store and P4 did so and then returned and put groceries away. It was then 2 p.m., which was when P4’s shift ended, so P4 left the facility. P4 did not see the VA during his/her shift because s/he was out in the community for most of the time which was typical. · P4 worked with the VA the week prior to the incident and at that time, P4 had no concerns with the VA and the VA did not mention anything concerning. The VA typically “stuck” to him/herself playing video games, which the VA did at that time. · The VA was not “talkative” and staff persons needed to “engage” with the VA and ask the VA how s/he was “doing,” or the VA would not “engage” with them. If the VA had any abnormal behaviors, staff person documented it. P4 was often the facility “driver” and took the VA to appointments and ask how the VA was doing during that time. P4 did not see any “warning signs” and was in a “state of disbelief” when s/he was told about the incident and said that s/he “wished there would have been more signs.” No one told P4 about any concerns with the VA and P4 was not aware of anything different in the VA’s life during this time. · P4 was not aware of the VA having any prior suicidal ideation but said that s/he was trained on the VA’s plans. Staff persons were also trained annually on mental health. If a staff person had concerns, the facility had crisis or “support” phone numbers and other resources available to them. Staff persons could also take the client to a local hospital. · P4 was not aware of any requirements for checking on the VA and said that the clients typically made their own breakfast and lunch. P4 usually saw the VA when s/he arrived for his/her shift around 10 a.m. At times, P4 took the VA on outings including to local restaurants and appointments. The VA was able to be driven somewhere and “dropped off,” including to local stores and the VA could also be unsupervised in the facility yard and neighborhood. For medical appointments, P4 drove the VA, waited for the appointment to be done, and then drove the VA home. P4 was not aware of the VA not attending the appointments s/he took the VA to. However, the VA was sometimes dropped off at a “group” appointment which was “hours long.” · P4 was not aware of the VA not taking his/her medications but said that s/he did not work the night shift when the VA’s medication was given. P1 and emails between P1, P2, the CM, the MHCM, and the FM provided the following information: · On August 2, 2025, at some point in the morning, P3 called P1 and provided information to P1 that was consistent with the information P3 provided regarding the VA leaving in the Lyft. · On August 2, 2025, at 9:15 p.m., P1 sent an email to P2, the CM, and the FM notifying them that the VA left the facility during the previous night. P1 also added that the VA “tended” to be up “a lot” during the middle of the night including going next door to get food out of the freezer which was “very concerning,” because the VA could also walk into someone’s home. P1 also said in the email that ”last week,” the VA tried to get his/her “med manager” at his/her clinic to discontinue his/her medications. P1 was going to “try to talk” to the VA “next week” but also asked P2, the CM, and the FM for “suggestions” and to let him/her know of “other concerns.” · On August 3, 2025, at 5:29 p.m., the FM responded to the email that s/he thought that the VA’s medications “need readjusting” and that the “last time” s/he picked the VA up to go shopping, the VA had a “meltdown.” (Note: There was no date regarding when the meltdown occurred.) The FM also said that an unknown staff person who was working the night s/he returned from taking the VA shopping did not “watch” the VA take his/her medication so the FM added, “Who knows if [the VA] is taking it?” The FM said “maybe” the VA needed “another evaluation” because the VA’s “behavior seems to be getting worse” and the VA was “mentally declining.” · On August 3, 2025, at 6:33 p.m., P1 responded via email stating that s/he would ensure to “follow up” and added that the “problem is the fact that [the VA] does not want to take [his/her] meds” and the VA “could use something different.” · On August 4, 2025, at 10:29 a.m., P1 again sent an email and included the MHCM and asking the FM what the “meltdown” looked like and what the VA was “saying” and “doing.” P1 also said in the email that the VA was diagnosed with “possible anosognosia” which was “lack of insight to [his/her] mental illness” and that someone with this diagnoses was not “simply in denial or being stubborn” but that their “brain can’t process the fact that their thoughts and moods don’t reflect reality.” P1 added that s/he left a message for a clinical director at the VA’s mental health clinic that morning to talk about getting an appointment for the VA to see a psychiatrist or psychotherapist that day but was waiting for a call back and that s/he would call again “later” that day if s/he did not hear back. P1 further said that the “issue” with the VA not taking his/her medication was “very concerning especially with [the VA’s] lack of insight” and P1 thought that the VA might need a “guardian” or “Jarvis through commitment to make [the VA] take [his/her] medications.” P1 said that s/he would let the FM, the CM, the MHCM, and P2 know once s/he heard from the clinic and if they could not get the VA in “soon,” that s/he would “seek other options.” · On August 4, 2025, at 12:02 p.m., P1 emailed the FM, the CM, the MHCM, and P2 stating that the VA was scheduled for a psychiatrist appointment on Wednesday, August 6, 2025, at 1:20 p.m. P1 had concerns that the VA would “refuse” to go to the appointment, so P1 asked the FM to “convince” the VA to go with P1. P1 also said that if the FM was in town that day, that maybe the FM could also come to the appointment. · At 12:13 p.m., P1 called the FM and asked the FM what the VA’s “meltdown” looked like. The FM said that approximately one or one-and-a-half weeks prior, when s/he took the VA on an outing, the VA told the FM that s/he wanted to get a “rope to hang” him/herself. The VA was also “screaming” about people, birds, bees, and the “air.” The FM was driving with the VA and had to “pull over” because it was “so bad” and the FM “worried” the VA might “jump out” of the car. P1 asked the FM if s/he told staff persons about this when the VA returned to the facility and the FM said s/he did not because the VA “calmed” him/herself. P1 was “upset” that the FM did not notify staff persons of this and told the FM that s/he should have notified P1 or other staff persons. P1 also told the FM that s/he should have taken the VA to the hospital but the FM said that s/he did not seek medical attention for the VA. · At 2:49 p.m., P1 received a voicemail message from P5 that the VA was deceased. · Following the VA’s death, a receipt was found in the VA’s bedroom which showed that on August 4, 2025, at 6 a.m., the VA purchased a rope. P1 spoke to P6 who worked the overnight shift and said that at 3:30 a.m., the VA came out of his/her bedroom to use the bathroom but then the VA returned to his/her room. P6 was not aware of the VA leaving the facility. Because of this, P1 thought that the VA “snuck out” at some point after 3:30 a.m. C3 then saw the VA at 7:30 a.m., so the VA had returned to the facility by then. C3 was the last person to see the VA because the VA’s “normal routine” would be that s/he would be in his/her bedroom until 2 p.m. P3 also told P1 that s/he did not see the VA when s/he arrived for his/her shift. The VA did not have any medications in the morning or during the day so staff persons did not need to wake the VA for that. · No staff persons were aware of any concerns about the VA prior to the incident. P3 and the VA were “close” so P1 thought the VA would have said something to P3. · The VA was typically “very withdrawn” and only told the FM about concerns. P1 said that only “twice” did the FM tell the facility about concerns: the concern regarding the “meltdown,” and on an unknown date in September 2024, when the VA “quit” his/her job and was having “auditory hallucinations” and did not feel “safe.” When the FM notified P1 of the concern in September 2024, P1 spoke to the VA and the VA was “fine” after that. · The VA had four hours of unsupervised time in the community and often took a nearby bus. The VA was asked by staff persons “several times” to “sign out” so staff persons knew where the VA was going, but the VA only did so “half” the time. At times, the VA called staff persons if s/he planned to stay out later.
· P1 stated that there were no requirements to check on the VA while at the facility. (Note: P1 told this investigator that s/he wrote and signed off on the VA’s plans as outlined above, which state that staff persons were to check on the VA hourly and/or also “attempt to engage” with the VA approximately every hour. When this investigator asked P1 why no staff person was aware of this, P1 said that s/he “did not know why” but that if staff persons did not know about this, that the “managers did not have them read the paperwork.”) It was in the “staff handbook” to say “hello” to the clients when staff persons arrived to work, but if the VA’s bedroom door was shut, it would be “presumed” that the VA was sleeping and staff persons could not go in the VA’s bedroom without “permission.” · At the time of the incident, the VA was prescribed one medication, which staff persons administered or documented if the VA refused. There were a “couple” times when there was “missed documentation.” Additionally, “earlier” in 2025 or prior, the FM notified the facility because the VA was out of medications so the FM took the VA to get his/her medications and learned that the VA had not seen his/her psychiatrist for six months. P1 spoke to a supervisory staff person (P7) who said that they had been dropping the VA off at his/her appointments. P1 then told P7 that staff persons needed to go in with the VA and stay with the VA and P1 thought that staff persons were doing so after. · On July 25, 2025, the VA had an appointment with his/her clinic because s/he wanted his/her medication discontinued but the clinic said that they would not discontinue it. · There was nothing in the VA’s plans about staff persons needing to go into appointments with the VA and staff persons could only go in if a client said it was “okay.” The VA did not want staff persons to attend his/her appointments. However, P1 told staff persons to communicate any concerns on a form for the doctor. The VA would often not tell staff persons about his/her scheduled appointments and/or would cancel appointments without telling staff persons. P2 provided the following information: · P2 had not worked with the VA long but said that the VA never indicated any thoughts of self-harm to P2 but the VA “hardly talked.” Staff persons “checked up on” the VA to ensure that s/he was “safe.” · The VA took his/her medication as s/he was “supposed to” and P2 was not aware of any times that the VA did not have his/her medications available to him/her. On or around July 24, 2025, the VA asked P2 if s/he could stop taking his/her medications because s/he “did not need them” and P2 told the VA that the VA needed to talk to his/her doctor. The following day, the VA spoke to his/her doctor who said that the VA “needed” the medications and the VA “agreed” to continue taking it. · The VA was able to be unsupervised in the community but staff persons typically tried to remain with the VA because the VA had a history of purchasing alcohol. P2 said that staff persons were not trained to do any specific checks on the VA when the VA was at the facility, but staff persons “always made sure” they knew where the VA was which was typically in his/her bedroom playing video games. Staff persons typically checked on the VA and other clients when they arrived at the facility for their shift. P2 was not aware of the VA sleeping in late but said that at times, the VA napped. · Staff persons were trained to go into appointments with the VA because if they did not, the VA found a way to leave without staff persons knowing. P2 was not aware of the VA leaving the facility during the night and said that the overnight position was asleep and that staff persons typically slept on a couch which was outside the VA’s bedroom door. · P2 last saw the VA the Wednesday (July 30, 2025) before the incident and the VA was his/her “normal” self, which included being “quiet.” P2 was not aware of any changes with the VA around the time of the incident. · Staff persons were trained on the VA’s plans in addition to “lots and lots” of training regarding mental health. P2 said s/he felt adequately trained. The MHCM provided the following information: · The VA was previously on a commitment for “mental illness” due to the VA’s diagnoses of schizophrenia and chemical dependency that ended on June 25, 2025. For approximately one year (June 2024 to June 2025), during the VA’s commitment, the MHCM worked with the VA and the last time the MHCM saw the VA was June 25, 2025, the end of the VA’s commitment. At that time, the MHCM asked the VA if s/he wanted to continue “voluntary” mental health services but the VA “refused” and said that s/he “did not need them.” During the year that the MHCM worked with the VA, the MHCM typically met the VA at the facility “face to face” each month and the MHCM “barely ever saw” staff persons. The MHCM had concerns regarding how much “engagement” or activities the facility offered the VA. However, the VA often “refused” activities and going out to do things. The VA also “liked” to sleep “a lot,” played video games, and kept to him/herself. The VA “lacked ambition,” including finding a job or continuing his/her education. The VA told the MHCM that s/he liked the facility and did not want to move. · The VA never expressed suicidal ideation to the MHCM and always denied such when asked. When the MHCM saw the VA, the VA “put on a happy face” and said s/he was “good” and “everything was fine.” A “very long time ago,” the VA expressed suicidal ideation and when that occurred, the VA typically “admitted” him/herself to a hospital or asked to go to the hospital. The MHCM was not aware of the VA telling anyone that s/he had recent thoughts of harm but the VA was the “closest” to the FM. The MHCM “wished” that the VA would have “opened up more.” · The MHCM was not aware of any requirement for staff persons to “visually check” on the VA. · The MHCM was aware of a couple times that the VA either did not take his/her prescribed medications or that the facility “ran out” and that it took a “few days” for the facility to get the VA’s medications. The MHCM was not aware of the VA missing scheduled medical appointments. The CM provided the following information: · The VA had a history of suicidal ideation but it was not “frequent.” Approximately three weeks prior to the incident, the VA told the FM that s/he should end his/her life but the CM was not aware of that until after the VA’s death. The CM was not aware of any concerns with the VA around the time of the incident. The VA had difficulty sharing things with others, including the CM and staff persons, and the VA could be “tormented by something” and no one would know. · The VA’s commitment ended because s/he was “doing well.” The CM “regularly” asked the VA if s/he liked the facility and the VA said that s/he wanted to continue living there. · The VA used Lyft for transportation but did not always notify staff persons when s/he left or where s/he was going. · The VA was able to have unsupervised time, including in his/her bedroom, and the CM did not think that staff persons “bothered” the VA “a lot.” The VA did not have any required supervision checks in his/her plans. The VA had “very little motivation” “lately” and stayed in his/her bedroom playing video games “all day” which the CM said was the “biggest issue.” · The CM was not aware of the VA not taking his/her medications but said that the VA was “sneaky,” and “manipulative.” The CM “encouraged” staff persons to check the VA’s mouth to ensure the VA was not “cheeking” his/her medications. · When staff persons took the VA to his/her appointments, the VA “waited” until staff persons left and then did not go in to the appointment. The VA had a “chronic issue” of “skipping appointments” but the CM thought that at some point, staff persons were “watching” the VA a “little closer.” The VA’s WebMed records provided the following information: · On June 26, 2025, the VA was seen at WebMed for an appointment and attended with an unknown facility “manager.” The VA said that s/he wanted to stop taking his/her paliperidone because s/he was “doing better.” The unknown staff person said that s/he felt that the VA’s medication was “very helpful” so the VA “agreed to continue the medication.” The VA did not have any suicidal ideation or “safety concerns.” Due to “difficulties” with transportation and “other factors,” the VA was to be seen again in three months with the “expectation that they will make an earlier appointment if needed.” (Note: There was no information regarding what these “difficulties” were.) · On July 25, 2025, the VA was seen at WebMed and said that s/he was there for a “medication change.” The VA wanted to get off “medication” and felt that things were “getting better” and that the medication was not “working.” The VA said that s/he “has to take medication due to [his/her] living situation.” It was noted that at the prior appointment, an unknown facility staff person said that the VA’s “symptoms” would likely return if the VA were to stop taking his/her medication. The VA’s provider told the VA that it was his/her “right” regarding taking medications but s/he should “consider the consequences.” The VA then “agreed” to take his/her current medication but said that s/he would be “interested” in stopping the medication if s/he moved to a different living situation. The VA said that s/he was “doing well” and denied suicidal ideation and any safety concerns. The VA “enjoyed” living at the facility. The VA was to be seen in three months or sooner if needed. The VA’s mental health clinic (MHC) records provided information that the VA was seen for individual and group therapy. The MCH records also provided the following information: · On February 18, 2025, the VA met his/her therapist and there were no “safety concerns to note.” The VA mentioned family members s/he regularly communicated with, including the FM. · The VA missed group sessions on March 5, 6, and 24, 2025. (Note: There was no reason documented as to why.) · On March 18, 2025, the VA attended an individual chemical dependency counselling session. The VA was to continue biweekly individual substance use disorder counseling and three weekly group therapy sessions per week. The VA said that staff persons and other clients were “very supportive of [his/her] recovery efforts.” There were no concerns noted. · On March 20, 2025, the VA missed a psychiatrist appointment. (Note: There was no reason documented as to why.) On March 31 and April 3, 2025, the VA cancelled his/her group session due to illness. On April 14, 2025, the VA cancelled group but there was no reason provided. On April 16 and 17, 2025, the VA “did not show” and there was no notation regarding what the appointments were for. On April 23, 2025, the VA cancelled an individual appointment. · On April 28, 2025, the VA’s “provider” spoke with the VA via phone to discuss the VA’s “progress” and to develop a “plan for step down to aftercare.” Beginning on May 13, 2025, the VA was to begin aftercare group once weekly. On April 30, 2025, the VA attended his/her chemical dependency group and shared “positive changes made in recovery” as well as “challenges.” (Note: The was no mention of what this was besides the weather as a “potential stressor.”) The VA wanted to “get back into sports,” including volleyball. · On May 1, 2025, the VA attended his/her chemical dependency group. The VA discussed that s/he wanted to teach a class on physical therapy. The VA was “scheduled” for graduation and “step down to aftercare” on May 9, 2025. · On May 5, 2025, the VA attended his/her chemical dependency group. The VA introduced him/herself to a new group member but was “minimally engaged” and left the group one hour early without “explanation” or notifying anyone. · On May 7, 2025, the VA attended his/her chemical dependency group. The VA “engaged” in an activity and stated that s/he used a “breathing exercise” at some point to “manage [his/her] anger.” The VA “identified alternate skills and processed the impact of abstaining from mood altering substance in relation to mental health.” The VA agreed to meet on May 8, 2025, to focus on anger management techniques and education related to “emotional regulation.” · On May 8, 2025, the VA attended his/her chemical dependency group and participated throughout the session. However, the VA appeared “distracted” and verbalized some “feelings of disengagement.” The VA participated in a mindfulness walk and was active in his/her graduation ceremony. · On May 9, 2025, it noted that the VA would “step down to after care group” and the first appointment was scheduled for May 13, 2025. On May 13 and 20, 2025, the VA “did not show” for relapse prevention group. The “provider” made two attempts to contact the VA and on May 22, 2025, the VA was “discharged” from the program. However, on this date, the “provider” contacted the MHCM to notify him/her of the VA’s “successful completion.” · On June 3, 2025, it was noted that the VA “successfully completed treatment.” However, the VA was to continue with individual therapy to address any mental health challenges and maintain supports in recovery efforts. However, there were no future appointments scheduled. [Note: As previously stated, the VA’s commitment ended June 25, 2025.] · On July 16, 2025, the VA went to the MHC for individual “therapy” which was “recommended” upon discharge from group therapy. However, the VA said that s/he was not “genuinely interested in therapy” but s/he felt “obligated” due to his/her previously being on commitment.” The VA said that s/he took his/her medication as prescribed. Given the VA’s history of missed appointments, time was spent with the VA discussing the “importance” of attendance and the necessity of cancelling when s/he was unable to attend. It was “mutually determined” that the VA would attend six individual sessions to explore and develop strategies to minimize risk for substance use. It did not indicate when future appointments were scheduled but on July 30, 2025, the VA was a “no show” for a scheduled appointment. The Mental Health Emergency or Crisis Response Policy said that staff persons were to call 9-1-1 for any mental health emergency including a client threatening to harm themselves, a client who was “distraught and out of control,” or a client who was “severely disoriented or out of touch with reality.” If a client talked about suicidal threats, had unusual behavior, or was “very depressed,” staff persons were to document this and attempt to redirect them. Staff persons were also to follow their individual crisis plan and call a crisis line or supervisory staff person. The Program Abuse Prevention Plan dated April 7, 2025, said that clients with self-injurious behaviors were “evaluated” and items that were part of their self-injurious behaviors were locked to limit availability to them if restriction was necessary. If a client had suicidal ideation they were to be evaluated for possible restriction of “sharps.” Staff persons were trained in crisis prevention intervention on a regular basis. Staff persons were to accompany clients to any outside programming until a client had “shown” that they could go independently. There was typically one staff person per four clients at the facility in addition to the house manager who worked 40 hours per week. (Note: It did not say what hours the house manager worked.) The Bluewater Resident House Guidelines said that transportation to local medical appointments was provided by the facility and “coordinated” by staff persons. If a client wanted an appointment, they were to check with staff persons for “available transportation and staff availability,” or clients may need to find their own transportation or “reset” the appointment. Facility documentation showed that P1, P2, P3, P4, P5, and P6 were trained on crisis intervention and de-escalation, substance abuse and mental health, suicide intervention and prevention, mental health certification, and on the Reporting of Maltreatment of Vulnerable Adults Act. P1, P2, P3, and P5 were also trained on the VA’s plans. There was no documentation to show whether P4 and P6 received training on the VA’s programs plans which was a violation of Minnesota Statutes, section 245D.09, subdivision 4a, which states that the license holder will ensure that staff persons review and receive instruction on the person’s coordinated service and support plan (CSSP) and CSSP addendum and how to implement those plans. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a), states that the license holder must provide services in response to the person’s identified needs as specified in the coordinated service and supports plan and the coordinated service and support plan addendum. Conclusion: A. Maltreatment: Information showed that on August 4, 2026, around 2:46 p.m., the VA was found deceased by suicide on the facility property by a neighbor. Although information from law enforcement said that P5 told them that the VA had stopped taking his/her medications and the FM had concerns that the VA was not taking his/her medications, on July 16, 2025, the VA told a provider that s/he took his/her medication as prescribed. Additionally, information from all sources was consistent that at some point prior to the incident, the VA said s/he wanted to stop taking his/her medications but that a doctor told the VA to stay on them and the VA did so. Facility documentation showed that in the months leading up to the incident, staff persons documented the VA’s medications as being given or refused, with the exception of one date when there was no documentation. There were also concerns that the VA did not attend his/her scheduled medical appointments. However, the VA’s plans showed that the VA did not need “supports” in this area yet P5 said that when they realized that the VA was not attending his/her appointments, a facility supervisor or the FM took the VA and staff persons “ensured” the appointment was scheduled. Information also showed that the VA did not want staff persons going into his/her appointments with him/her and staff persons often did not know when future appointments were scheduled. The FM said that on July 4, 2025, when s/he last saw the VA, the VA had a “psychiatric meltdown.” However, another family member saw the VA the Sunday before the incident and said that the VA was “fine.” The FM also said that the VA would not have told staff persons about his/her intent to harm and would have denied it if asked and the VA’s plans and interviews with staff persons and the VA’s case managers showed that the VA typically only told the FM about the concerns. The VA did not indicate any self-harm to staff persons, the CM, or the MHCM and the FM did not tell staff persons that the VA told him/her that s/he wanted to get a “rope to hang” him/herself until approximately two-and-a-half hours prior to the VA being found deceased. The VA’s Individual Abuse Prevention Plan stated that staff persons were to “touch base” with the VA a “minimum of every hour” to see how the VA was doing and try to talk to the VA about “any symptoms” s/he may be having. Staff persons were to also “attempt to engage” with the VA approximately every hour to see if there was “anything they could do” for the VA. The VA’s Individual Resident Placement Agreement stated that staff persons were to do hourly check-ins with the VA to ask the VA how s/he was doing. However, no staff person, including supervisory staff persons and P1, who was a part of writing the VA’s plans, was aware of this and there was no documentation to show that staff persons did so which was a violation of Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Additionally, the VA’s plans showed that if staff persons noticed that the VA was in his/her bedroom “a lot,” they were to talk to the VA or offer the VA an activity, and staff persons were also to offer to help the VA make something for breakfast and lunch. However, no staff person saw the VA at any point on August 4, 2026, and information showed that the VA was likely last seen by a staff person on August 3, 2025, around 8 p.m., when the VA received his/her medication, which was at least 18 hours and 45 minutes without a staff person checking on the VA. Although it was not determined whether hourly checks would have prevented the VA's death, given that no staff person was aware of or followed the VA’s plans for hourly checks and that the VA had a history of thoughts of suicide, and prior hospitalizations for suicidal ideation, staff persons failure to provide those checks presented a risk that endangered the VA's physical and mental health and safety. Therefore, there was a preponderance of the evidence that there was a failure or omission to supply the VA with care or services which were reasonable and necessary to maintain the VA’s physical or mental health or safety. 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 documentation showed that P1, P2, P3, P4, P5, and P6 were trained on crisis intervention and de-escalation, substance abuse and mental health, suicide intervention and prevention, mental health certification, and on the Reporting of Maltreatment of Vulnerable Adults Act. P1, P2, P3, and P5 were also trained on the VA’s plans. Given that two of the VA’s plans, the Individual Resident Placement Agreement and the Individual Abuse Prevention Plan, each said that staff persons were to check in with the VA hourly, yet no staff person, including P1 who wrote and signed off on the plans, was aware of this or implemented as such, and that P1 said that if staff persons did not know about this, that the “managers” did not have them read the paperwork, and that P4 and P6 were not trained on the VA’s plans, individual staff person responsibility was mitigated and 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. Although the VA was found deceased, because it was not determined whether hourly checks would have prevented the VA’s death, it was unknown if the VA’s death was a result of the maltreatment. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were followed but not adequate including that P1 was trying to get the VA a new psychiatrist the morning of the incident. After talking to the HDC, P1 found out that the VA had been cancelling “all” of the VA’s psychiatrist and therapy sessions over the past six months. P1 had also discussed with the FM the morning of the incident obtaining possible guardianship for the VA because the VA did not like taking medications and had “minimal insight” into his/her illness. P1 thought that a guardian could help ensure that the VA received proper medication because the VA’s decision making regarding them was not good for the VA’s mental health. The VA tried to get the only medication s/he took, Invega, discontinued the week prior by his/her clinic. There were no similar incidents. The facility did not provide additional training or make changes following the incident. Action Taken by Department of Human Services, Office of Inspector General: On August 24, 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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