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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: 1072143-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Brittany Dolen 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) used a vulnerable adult’s (VA’s) phone, posed as the VA and invited an unknown community person (CP) to the facility where the CP sexually assaulted the VA. Date of Incident(s): October 16 and 17, 2024 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 October 6, 2024, from documentation at the facility, law enforcement records; and through seven interviews conducted with the VA, the VA’s Guardian (G), two supervisory staff persons (P1 and P2), two facility residents (R1 and R2), and the SP. The VA was diagnosed with major depressive disorder, fetal alcohol syndrome, and mild intellectual disability. The VA’s plans showed that the VA “demonstrated a lack of personal boundaries” in the past, and often needed prompts to maintain personal boundaries. The VA required a 24-hour plan of care, without constant supervision, but with staff persons being available to the VA in case of an emergency. The VA enjoyed socializing with those around him/her and had a desire to meet people and form relationships. The VA’s Coordinated Services and Support Plan Addendum stated that the VA did not require any rights restrictions. Although it was alleged that the VA was sexually assaulted by the CP, the focus of this investigation was on the care and supervision provided to the VA at the facility during the incident, and not the sexual assault by the CP. The Department of Human Services did not have jurisdiction to investigate the alleged sexual assault because the CP was not a staff person. The VA said that s/he was “not allowed” to let staff persons use his/her phone, but “sometimes” the VA allowed the SP to use his/her phone when the SP’s phone was not charged, and the SP did not want to go to his/her vehicle to get his/her charger. The VA did not know what the SP did when s/he used the phone because the VA “deleted everything.” The SP told the VA to delete everything, so the VA did. The VA said that what the SP did on the VA’s phone was “none of [the VA’s] business.” The VA denied the SP used his/her phone the night of the incident, and did not answer additional questions regarding the incident that occurred because s/he “did not want to get anyone in trouble.” The SP provided the following information: · On October 17, 2024, around 12 or 12:30 a.m., the CP arrived at the facility and the VA told the SP that they were going to “hang out” in the VA’s bedroom. The SP had no prior knowledge that the CP was coming over. · The VA and the CP were in the VA’s bedroom for “thirty to forty minutes” when the VA came out of his/her bedroom and asked the SP to tell the CP to leave. The SP did so but the CP would not leave so the SP called 9-1-1. Before LE arrived (a few hours later), R1 and R2 helped get the CP out of the facility. The SP was “really scared” when the CP would not leave the facility and said s/he should have “never let” the CP inside. · Residents at the facility were not supposed to have visitors over in the middle of the night. When the VA had visitors over, the SP supervised them and made sure the VA’s bedroom door was open while the visitor was there. The SP “did not remember” if the VA had a rights restriction in place regarding visitors but said s/he checked on the VA and the CP while the CP was there. The SP did not hear anything that indicated there was anything wrong or anything occurring in the VA’s bedroom while the CP was visiting. · The SP denied inviting the CP to the facility and denied using the VA’s phone. Information obtained showed the following: · The VA did not have a rights restriction regarding having visitors to the facility. The facility had a visitation policy and visiting hours were “supposed” to end around 9 or 10 p.m. Residents were “supposed” to invite people only if they knew them. P2 said the facility had “designated quiet hours” from 11:30 p.m. until 6:30 a.m. and during that time, they should not be “loud or disruptive.” · The G thought the VA needed staff supervision when s/he had visitors. The G also thought visitors were to “sign in or out” of the facility and that there was a curfew so visitors could not be at the facility past 9 p.m. · On the day of the incident prior to the CP coming over, R1 overheard a phone conversation between the VA and an unknown person. The VA invited that person to the facility. R1 did not provide any additional details. · The VA had a history of meeting individuals on the internet and inviting them to the facility, and the G had “concerns” with the VA living with individuals of the opposite sex due to his/her poor sexual boundaries. The G thought the VA invited the CP to the facility on the night of the incident. · R1 and R2 said the VA often brought “dates” to the facility and R1 “warned” the VA about who to bring into the facility. Neither R1 nor R2 had concerns with the SP or the facility. Law enforcement (LE) records provided the following information: · On October 16, 2025, the VA invited the CP to the facility via text message. Law enforcement found “over seven hundred” text messages between the VA and the CP that had been deleted from the VA’s phone. There were messages sent to the CP from the VA’s phone on the day of the incident that were sexual in nature and were sent prior to the SP beginning work.
· LE talked to the CP who said that s/he and the VA met one week prior to the incident and had messaged via text and snapchat. The night of the incident, the VA invited the CP to the facility and told him/her to “knock and open the door.” While at the facility, the CP and the VA had “consensual” sexual contact. · LE talked to the VA who said s/he did not know the CP prior to him/her coming over. The SP was “pestering” the VA to invite the CP over and the VA “never” texted or messaged the CP to come over. The VA said that s/he had sexual contact with the CP but denied the sexual contact was consensual. The SP told the VA not to call 9-1-1 because the SP was “worried” about his/her job, but R1 told the VA to call 9-1-1. The VA also said that the SP “deleted everything” off of the VA’s phone related to the CP but did not know what was deleted. · LE talked to the SP who said the CP was in the VA’s bedroom for approximately 20 minutes and the VA’s bedroom door was open at the time. The morning after the incident, The SP told P2 that the VA “invited someone off the internet” to the facility and that the CP “refused” to leave. The VA had invited different people over to the facility several times “to have sex.”
· LE talked to P2 who told LE that the VA told him/her that the CP was a pizza delivery person. A document titled Resident Visitor Policy showed that any visit to the facility had to be prearranged with an appropriate supervisor at least one hour in advance, and that individuals who arrived unannounced could be asked to leave the property. In addition, any visitor to the facility needed to be authorized prior to the visit by clients’ guardians and case managers, and no visitors were allowed at the facility after 9:30 p.m. If a visitor would not leave the facility upon request of a staff person or resident, law enforcement would be contacted. The facility’s personnel files showed that P1, P2, and the SP were all trained on the VA’s plans and the Reporting Maltreatment of Vulnerable Adults Act. Relevant Rules/Statues: MN Statutes, section 245D.04, subdivision 3, paragraph (b), clause (4) states in part that a person’s protection related rights included the right to choose the person's visitors and time of visits and have privacy for visits with the person's spouse, next of kin, legal counsel, religious adviser, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person's bedroom. Conclusion: Information showed that the VA had a history of meeting individuals online and inviting them to the facility. On the date of the incident, R1 overheard a phone call where the VA invited someone to the facility. Although the CP came to the facility around 12 a.m. and then refused to leave, the VA did not have a rights restriction that restricted his/her visitors. In addition, there was no information to support that the SP used the VA’s phone and invited the CP to the facility, and when the VA requested the SP’s assistance with getting the CP to leave, the SP did so and then contacted law enforcement when the CP would not leave. Therefore, there was a preponderance of the evidence that neglect did not occur. It was determined that neglect did not occur (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an internal review and determined that their policies and procedures were adequate but not followed when the SP allowed a visitor into the facility after the time identified in the policy. The facility found their visitation policy to be “potentially confusing” for staff persons, and it was updated to provide more guidelines with clear actions steps regarding visitation in the facility. Action Taken by Department of Human Services, Office of Inspector General: On May 30, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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