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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: 1125078-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux carla.harvieux@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual intercourse with a vulnerable adult (VA). Date of Incident(s): Prior to September 23, 2025 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 2, paragraph (c): Any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast. Summary of Findings: Pertinent information was obtained during a site visit conducted on October 16, 2025; from documentation at the facility, records from a law enforcement agency, and the VA’s medical records; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP), the VA, and the VA’s guardian (G). Facility documentation showed that the VA was diagnosed with borderline personality disorder, autism spectrum disorder, schizoaffective disorder, and post-traumatic stress disorder/complex trauma. The facility provided continuous three to one staffing for the VA at the facility and in the community. No other individuals resided at the facility with the VA, and the facility had a video recording system that recorded the facility’s common areas. The VA had a history of poor boundaries and had been previously assaulted. The VA might cooperate in abusive situations, and staff persons were to immediately take the VA to the emergency department of a hospital and notify a law enforcement agency if they thought that the VA had been assaulted. The VA had a history of providing inaccurate information, but staff persons were to take his/her statements seriously and act when the VA voiced concerns. If the VA’s non-preferred staff persons worked at the facility, or the VA felt frustrated, lacked sleep, felt unheard/accepted, had physical pain, felt s/he lacked control of his/her life, or if there were changes in his/her routine, s/he was denied access to items, when the weather changed or when there were transitions, the VA might behave aggressively toward others, engage in self-injurious actions, or attempt to leave the facility without supervision. In the community, the VA might call out for “help” or sit in streets to get attention or to be taken to a hospital. If the VA engaged in these actions, staff persons were to redirect the VA, remind the VA that they were there to support him/her, and encourage the VA to talk with them if s/he wanted to. The G restricted the VA’s right to associate with persons of his/her choice, the right to receive/send mail, electronic correspondence or communications, or use telephones. The VA had no unsupervised time at the facility or in the community, and staff persons were to supervise the VA’s use of electronic devices and telephones. The VA enjoyed listening to music, playing games, and using “fidget” items. The VA’s family was important to him/her, and s/he wanted to work in the community. Interviews conducted in unison by this investigator and a law enforcement officer (LEO), facility documentation, records from the law enforcement agency, the VA’s medical records, and the facility’s Internal Review, provided the following: · The VA said that on a date s/he could not recall in mid-September of 2025, the SP (who was a supervisory staff person), took him/her to an alley in a community location, placed tape over the VA’s mouth, bound the VA’s hands and feet with zip ties, and had sexual intercourse with him/her. In addition, the SP threatened the VA with a handgun during the incident and shot at the VA. The VA was grazed by bullets but was not seriously injured. The incident ended when the SP called P1 and P2 to come get the VA, and the SP left the alley in a car with his/her friends. P1 and P2 took the VA back to the facility then to the emergency department of a hospital a short while later when the VA asked to be evaluated. · The VA’s medical records showed that on September 18, 2025, the VA was evaluated at the emergency department of the hospital for “antisocial personality disorder.” At the hospital, the VA attempted property destruction and had potentially self-harming behaviors, but hospital employees intervened. The VA left the hospital without supervision, and the facility staff persons who were with the VA followed him/her into the community. Staff persons redirected the VA to return to the hospital and s/he was admitted to the unit of the hospital that provided services to adults with mental illnesses. The VA told hospital employees that a staff person “assaulted” him/her two to three days ago, but when hospital employees asked the VA for details about the assault, the VA said that s/he did not like the facility and wanted to be admitted to the hospital. On September 18, 2025, the VA was not examined for sexual assault because s/he recently had been examined for sexual assault and a health care professional determined that a “collection of new evidence would not provide any additional information.” The VA was discharged back to the facility, but on September 20, 2025, the VA was admitted to the unit within the hospital that provided care to adults with mental illnesses. The medical records did not show that the VA was recently grazed by bullets, and no information showed that the VA provided information regarding guns, zip ties on his/her hands/feet, or tape on his/her mouth, to hospital employees. The G supported the VA’s hospital admission and thought that the VA would benefit from inpatient care. · The SP said that the VA always had three to one staffing based on his/her needs and the facility had a video recording system because of the VA’s history of providing inaccurate information. According to the SP, there were no occasions when s/he or any staff person transported the VA alone or took the VA into the community without assistance from other staff persons. The SP denied that s/he took the VA to an alley and denied that s/he placed tape on the VA’s mouth or zip ties on the VA’s hands and feet. The SP stated that s/he did not have sexual intercourse with the VA. The SP did not take the VA’s statements personally due to the VA’s history of providing inaccurate information and knew that the VA’s statements were related to his/her mental health diagnoses. · P1 and P2 provided consistent information that they often worked with the SP, and that three staff persons always worked with the VA. There was not a time when the SP worked alone with the VA or asked them to pick up the VA from an alley. In addition, P1 and P2 did not see the SP or any staff persons with tape, zip ties, or firearms/handguns at the facility. · P3, who was an administrative staff person, said that the VA often targeted new staff persons, and might target staff persons who were the same gender as the VA. The VA recently targeted the SP because s/he was a newer employee. P3 had no concerns regarding the SP’s work at the facility or the care that staff persons provided to the VA. A review of the recordings from the time frame near the VA’s evaluations at the hospital on September 18 and 20, 2025, did not show the VA leaving the facility with the SP, or P1 and P2 leaving the facility without the VA and then returning to the facility with him/her. Information from the LEO showed that the law enforcement agency investigated the allegations in this report but took no further action. The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s policies and procedures prior to the incident. Conclusion: Facility documentation showed that the VA’s diagnoses included borderline personality disorder and schizoaffective disorder, and the facility provided three to one continuous staffing for him/her. The VA was vulnerable to maltreatment and had a history of providing inaccurate information. When the VA voiced concerns, staff persons were to take him/her seriously, then take appropriate action. The VA said that in mid-September of 2025, the SP took the VA to a community location, placed tape over the VA’s mouth, bound his/her hands and feet with zip ties, and had sexual intercourse with him/her. In addition, the SP shot at the VA, who was grazed by the bullets, but was not seriously injured. After the incident, P1 and P2 picked the VA up at the community location and took him/her back to the facility, and then to the hospital after the VA asked to be evaluated. The VA’s medical records showed that the VA was evaluated at the hospital for antisocial personality disorder and admitted to the unit of the hospital that provided services to adults with mental illnesses. At the hospital, the VA did not provide information to hospital employees that was consistent with the information s/he provided in an interview with this investigator and the LEO. P1, P2, and the SP, each stated that the incident did not occur, and according to P3, the facility’s video recordings did not show the SP leaving the facility with the VA, or P1 and P2 returning to the facility with the VA. The LEO investigated the allegations in this report and took no further action. On the date of the site visit, the VA was in the hospital. Although the VA said that the SP placed tape on his/her mouth, bound him/her, had sexual intercourse with him/her, and shot at him/her in the community, given that the VA had a history of providing inaccurate information, that the video recordings did not show the VA and the SP leaving alone or the VA returning with P1 and P2, that the VA’s medical records did not show injuries consistent with being grazed by bullets, and that the law enforcement agency investigated the allegations, but took no further action, there was not a preponderance of the evidence whether the SP had sexual intercourse with the VA. It was not determined whether sexual abuse occurred (any sexual contact or penetration between a facility staff person or a person providing services in the facility and a resident, patient, or client of that facility. Sexual contact is defined by Minnesota Statutes, section 609.341, as the intentional touching of the intimate parts with sexual or aggressive intent. 'Intimate parts' includes the primary genital area, groin, inner thigh, buttocks, and breast). Action Taken by Facility: The facility completed an Internal Review which determined that their policies and procedures were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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