William L. Grade dutifully checked with the front desk of his north Minneapolis nursing home one day last month and went out the door for his usual morning walk.
Less than three hours later, the 55-year-old was found dead in the Mississippi River a quarter-mile away. Now state and county officials are trying to figure out how he drowned and whether the home, which has an extensive history of state licensing violations, monitored him adequately.
Grade, whose body was found about noon on Sept. 25, had entered the Camden Care Center 16 days earlier for therapy and was not expected to be there long, said cousin Glenn Pauls.
"Nobody knows exactly why Billy ended up in the water," said Pauls, who lives in Colorado.
The Hennepin County Sheriff's Office, in a portion of its investigative report released Friday, said Grade was scheduled to see a psychologist on the day of his drowning but also "was in good spirits." Grade's pastor said he had a heart condition setback just before entering the nursing home.
Pauls said his cousin was not being treated at the care center for mental illness or mental deficiencies, and he said local investigators and nursing home staff were vague about the details of Grade's death.
The Hennepin County medical examiner ruled that Grade drowned but has so far left the specific manner of death undetermined. Pauls said the medical examiner's office told him his cousin "tested negative for drugs or alcohol" and there were no obvious signs of injury.
Pauls said he had seen Grade about a month earlier, "and he said everything was OK. There was no suicide note or anything."