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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: 1122887-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Anna.parkin@state.mn.us Suspected Maltreatment Reported: Allegation One: It was alleged that a supervisory staff person (SP) took funds from four vulnerable adults (VA1-VA4). Allegation Two: It was alleged that the SP “flirted” and “touched” VA4 and mentally bullied VA4. Allegation Three: It was alleged that the SP sent VA1 nude pictures of him/herself and had a sexual relationship with VA1. Allegation Four: It was alleged that the SP gave VA1 marijuana. Date of Incident(s): unknown 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 (b), clause (2); subdivision 2, paragraph (c); subdivision 9, paragraph (b), clause (1); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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. In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult. 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 3, 2025; from documentation at the facility and law enforcement records; and through 10 interviews conducted with two supervisory staff persons (P1 and P2), a facility staff person (P3), VA1-VA3, and VA2’s-VA4’s respective guardians (G1-G4). A law enforcement officer (LEO) interviewed another facility staff person (P4) and the SP and that information was also included below. Attempts were made via phone and certified mail to contact and interview the SP but the SP did not respond to the requests. VA4 was not interviewed due to his/her disabilities and did not manage his/her finances. On August 25, 2025, an anonymous email was sent to the facility that provided the following information: · The SP stole money from VA1 and used VA2’s-VA4’s money for his/her own personal use. · The SP started “random[ly] touch[ing]” and “flirt[ed]” with VA4. VA4 became “possessive” so the SP focused more on VA1. The SP used VA1 to “bully” VA4 on a daily basis. [Note: There were no specific examples provided.] · The SP had a sexual relationship with VA1 and sent nude pictures of him/herself to VA1. Pictures attached to the email included pictures of the SP’s genitals that were taken at the facility and sent to VA1’s phone. · The SP provided VA1 with marijuana. P1 and P2 provided the following information: · In February 2025, P1 and P2 each received text messages from an unknown phone number saying s/he had concerns with VA1’s boundaries with the SP. P2 spoke to the SP who denied any concerns and said it was sent by a family member the SP had issues with. · In March or April 2025, P3 contacted P2 and said that they were not able to find the SP at the facility. Later on, P3 found out that the SP had been in VA1’s bedroom with the door closed for “an extended” length of time. P2 talked with the SP who said s/he had been watching VA1 play video games and P2 reminded the SP about his/her boundaries with clients. · P2 stated in July 2025, the SP contacted P2 and requested to update his/her timesheet because although the SP was not at the facility or scheduled to work, s/he met VA1 and attended a medical appointment with VA1. The SP said that s/he drove VA1 to a medical appointment using VA1’s car because VA1 had smoked marijuana so was unable to drive. The SP received written corrective action. According to the facility’s Code of Conduct, staff persons were not to not engage in any sexual activity with clients, including but not limited to sexual advances, threats related to any sexual activity, sexual “kidding” or “teasing,” or obscene photos. Staff persons also did not borrow or loan money with the clients. According to the facility’s Drugs and Alcohol policy, the facility maintained a workplace free from the effects of drugs, alcohol, chemicals, or abuse of prescription medications. Staff persons were prohibited from using, selling, manufacturing, distributing, or possessing illegal drugs, controlled substances, or chemicals while on facility business, providing services, using a facility vehicle, or on facility property. Facility documentation showed that staff persons, including the SP, were trained on VA1’s-VA4’s plans, the facility’s code of conduct, the facility’s Drug and Alcohol policy, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Allegation One: It was alleged that the SP took funds from VA1-VA4. VA1 was diagnosed with a mild developmental disability and depression. VA1 had unlimited unsupervised time in the community but told staff persons where s/he was in case of an emergency. VA1 was not subject to guardianship. According to VA1’s Risk Assessment Detail, VA1 managed his/her own finances and might not recognize if his/her funds were mismanaged. Supervisory staff persons oversaw VA1’s rep payee account with the facility and reported any suspicious activities or transactions. VA1 met with the SP once per week to compare his/her personal ledger with his/her online account for accuracy. VA2 was diagnosed with a moderate developmental disability. VA2’s ISSA Assessment Detail stated: · VA2 did not manage his/her own finances because s/he would “buy what [s/he] wants when [s/he] wants” if s/he had money. VA2 did not have the ability to budget his/her own finances and was “easily manipulated” by other persons when it came to finances. VA2 required assistance from his/her family member, the SP, and staff persons to manage finances. · The facility and staff persons assisted VA2 with purchases, getting receipts, balancing accounts, depositing money, and documenting purchases. VA2 was allowed small amounts of cash on hand that was not required to be documented. Staff persons observed for signs of abuse and reported it per policy. The SP maintained financial documentation that was reviewed weekly and P2 reconciled accounts and reviewed receipts monthly. VA3 was diagnosed with autism spectrum disorder. VA3’s Risk Assessment Detail stated that VA3 understood coins and dollar bills but not “bigger bills.” VA3 would not know if someone gave him/her correct change or mismanaged his/her money. VA3 was not able to budget his/her own finances. VA3 required staff persons and the facility to maintain all of his/her finances including paystubs and cash. Staff persons assisted VA3 with purchases, getting receipts, balancing accounts, and documenting purchases. If staff persons observed signs of abuse they reported according to facility policies. The SP maintained financial documents and reviewed them weekly and P2 reviewed receipts and reconciled accounts on a monthly basis. VA4 was diagnosed with autism spectrum disorder. VA4’s Risk Assessment Detail stated that VA4 did not have the ability to budget his/her own finances and was “easily manipulated” by other persons. Staff persons and the facility maintained all VA4’s finances because VA4 might not recognize if someone mismanaged his/her funds. VA4 was learning how to manage small amounts of cash according to his/her financial consent form that VA4 did not need to document or turn receipts in for. VA1 denied that the SP used any of his/her funds. VA2 stated the weekend of August 25, 2025, the SP took VA1-VA4 to an activity. On the way, they stopped for VA2 to take $200 cash out of an ATM. VA2 spent the full $200 on activities that day. VA2 had the receipt but did not know what happened to it. VA2 denied any concerns with staff persons, including the SP, using his/her funds. P2 stated that all staff persons had access to VA1’s-VA4’s petty cash. The SP documented and balanced VA1’s-VA4’s finances weekly and P2 then reviewed them monthly. P2 reviewed VA1’s-VA4’s finances from January through August 2025 and noticed two concerns: · On March 31, 2025, VA2 had $14.43 in petty cash but on April 1, 2025, had $0 petty cash. P2 was not sure how this occurred, and the facility reimbursed VA2 the funds. · On approximately September 28, 2025, VA2 was missing $240 from his/her petty cash compared to the ledger. P2 balanced VA2’s accounts the end of August 2025 and they were all accurate at that time. · P2 asked the SP about VA2’s missing $240 cash. The SP explained that VA2 took $200 out of an ATM the weekend prior and the SP was not able to document the $200 withdrawal on VA2’s ledger. The SP denied knowing about the other $40. P2 asked VA2 who said s/he used $200 cash the prior weekend and P2 verified the $200 cash withdrawal online. The facility could not account for the $40 so the facility reimbursed VA2. · P2 stated there were no concerns with VA1’s, VA3’s, or VA4’s finances. According to the law enforcement report, the SP stated s/he did monthly audits of VA1’s-VA4’s finances. [Note: there was no other discussion on their finances.] G1 stated that P2 contacted G1 about the missing $40 from VA2’s bank account and the facility reimbursed VA2 the funds. G1 did not have previous concerns with the facility. G3 was contacted by P2 about the allegation and P2 said that VA3’s funds were not taken. G2-G4 did not have previous concerns with VA2’s-VA4’s finances or the facility. Conclusion Allegation One: Although an anonymous report to the facility stated that the SP took funds from VA1-VA4, and that VA2 was missing $14.43 and $40 from his/her petty cash, given that P2 reviewed VA1’s, VA3’s, and VA4’s accounts and there were no noted concerns; all staff persons had access to VA2’s petty cash; and that VA1 denied the SP used VA1’s funds, there was not a preponderance of the evidence whether a staff person willfully used, withheld, or disposed of VA1’s-VA4’s funds. It was not determined whether financial exploitation occurred (In the absence of legal authority a person willfully uses, withholds, or disposes of funds or property of a vulnerable adult). Allegation Two: It was reported that the SP “flirted” and “touched” VA4 and mentally bullied VA4. According to VA4’s Risk Assessment Detail, VA4 would “go with any person” if s/he was asked and was not able to defend him/herself. VA4 would not tell anyone if s/he was sexually abuse if s/he was told not to. VA4 did not have skills necessary to deescalate a situation. Staff persons spoke to VA4 about how to respond to abuse and who to report to. If staff persons observed or suspected abuse occurring, they moved VA4 away from the abuser and ensured further abuse did not occur. VA4 stated on one occasion, when s/he was in the SP’s office, the SP told VA4 to “get the fuck out of my office right this instant.” VA4 was upset and told P4 about the incident. VA4 did not have any other concerns with how the SP treated VA4. P4 stated that the SP allowed VA1 to “boss” the three other clients around but never saw inappropriate touching between the SP and the clients. Conclusion Allegation Two: Although an anonymous report to the facility stated that the SP “flirted” and “touched” VA4 and mentally bullied VA4, there was no specific information provided about the incidents. While VA4 said that on one occasion the SP told VA4 to “get the fuck out of my office” which upset VA4, given that it was single incident and there was no other information to support the anonymous information, there was not a preponderance whether the SP used repeated or malicious language to VA4. It was not determined whether emotional abuse occur (Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). In addition, given that there was no specific information provided in the anonymous email about the SP’s flirting and touching VA4, that P4 did not see inappropriate touching between the SP and the clients, that VA4 did not have any other concerns with how the SP treated VA4, and that there was no additional information to support these allegations, there was a preponderance of the evidence that the SP did not have sexual contact with VA4. It was determined sexual abuse did not occur (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). Allegation Three: It was reported that the SP sent VA1 nude pictures of him/herself and had a sexual relationship with VA1. The facility had two levels. VA1’s bedroom and the staff office were on the lower level of the facility. According to VA1’s Risk Assessment Detail, VA1 had a history of past sexual abuse and staff persons were trained on the facility’s vulnerable adult policy and assisted as needed to ensure VA1’s safety remained a priority. If VA1 felt s/he did “something wrong” or would get in trouble, VA1 would not report abuse. VA1 might not tell staff persons about incidents so staff persons worked with VA1 to get the facts and notify a supervisory staff person. VA1 provided the following information to this investigator and the LEO: · On multiple previous unknown dates, the SP texted VA1 nude pictures including ones of the SP’s genitals. The SP texted “naughty stuff” to VA1 along with the pictures. At some point, VA1 deleted the pictures and text messages from his/her cell phone. · On at least five prior occasions, the SP and VA1 had sexual intercourse. Most of the time the sexual intercourse happened at the facility in VA1’s bedroom. There were also multiple occasions when VA1 met the SP when s/he was not working in public locations, such as parks and restaurants. On one of those occasions, the SP and VA1 had sexual intercourse while at the park. On October 2, 2025, the LEO had a forensic exam done on VA1’s cell phone. There were two phone numbers associated with the SP that included text messages (there was no information provided what was written in the messages) and pictures from June 4, 2024, to October 2, 2025. There were multiple messages from VA1 to the SP and multiple pictures of the SP sent to VA1. The exam report stated that there were nude pictures of VA1 but did not state whether there were nude pictures of the SP. P2 stated that after the internal investigation began on an unknown date, VA1 came to P2 and said that s/he had sexual intercourse with the SP. VA1 also said that the SP and VA1 sent inappropriate pictures of themselves and messages to each other. P2 felt that VA1 was being honest with the information because VA1 was a quiet person so for him/her to come forward and tell P2 was unusual. After the SP was suspended, P2 went to the staff office that the SP used and found items that were sexual in nature. P3 and P4 provided the following information: · P3 and P4 each stated that the SP seemed to favor and spend more time with VA1 than the other clients. P3 stated on approximately May 16, 2025, when P3 arrived at the facility s/he could not find the SP. P3 went to the SP’s staff office and did not see the SP. P3 noticed that VA1’s bedroom door was closed. P3 tried calling the SP “several times” on his/her cell phone but the SP did not answer. Approximately two hours later, the SP walked upstairs and P3 asked the SP where s/he had been. The SP said s/he had been in VA1’s bedroom watching him/her play video games. · P4 stated that all overnight staff persons slept upstairs because three of the other clients’ bedrooms were there but the SP who slept downstairs by VA1’s bedroom. On a previous unknown date, VA1 told P4 that s/he had been to the SP’s house and met the SP’s family member. P4 had “never” known VA1 to “lie.” VA2 told P2, this investigator, and the LEO that the SP slept downstairs while s/he worked overnight while all other staff persons slept upstairs. The SP provided the following information to the LEO: · On previous occasions, the SP sent his/her previous significant other nude pictures of him/herself. Later, the previous significant other forwarded the pictures to the facility because s/he wanted the SP fired. The SP initially denied sending the nude pictures to VA1 but when the LEO discussed the forensic exam of VA1’s phone and VA1’s information provided to the LEO, the SP acknowledged that VA1 was “telling the truth.” The SP said that VA1 “initiated everything” including sending pictures of their genitals to each other and engaging in sexual conversations. The SP stated that s/he “fell in love” with VA1. · Sometime in 2024, the SP stood in the kitchen and VA1 started “groping” the SP. The SP did not remember how many times s/he had sexual intercourse with VA1 but it was more than once in VA1’s bedroom. The law enforcement report was submitted to the county attorney for review for third degree criminal sexual conduct. Conclusion Allegation Three: A. Maltreatment: VA1 provided information to P2, this investigator, and the LEO that the SP and VA1 had sexual intercourse on multiple previous occasions; and the SP told the LEO that s/he had sexual intercourse with VA1 more than once. Therefore, there was a preponderance of the evidence that the SP and VA1 had sexual intercourse. It was determined that 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). 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. The SP was trained on VA1’s plans, the facility’s code of conduct, and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. The SP was a supervisory staff person who was responsible for the care and supervision of VA1. The SP was responsible for maltreatment of VA1. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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 sexual abuse for which the SP was responsible was “recurring and serious” maltreatment. The SP had sexual intercourse with VA1 on multiple occasions. The SP was disqualified from providing direct contact services. Allegation Four: It was reported that the SP gave VA1 marijuana. According to VA1’s ISSA Assessment Detail, VA1 used marijuana in the past when depressed. [Note: There was no mention of staff persons supporting VA1 with sobriety.] VA1 was older than 21 years of age. VA1 stated on multiple occasions, the SP gave VA1 marijuana, including edibles while the SP worked at the facility. When VA1 used the marijuana, it made him/her more relaxed. VA1 denied that the SP used the marijuana. P3 stated on one previous occasion, the SP told P3 that there were “times” when VA1 came to the SP’s house and smoked marijuana with the SP’s family member. Relevant Rules and Statutes: Minnesota Statutes, section 342.09, subdivision 1, stated in part that an individual 21 years of age or older may use or possess cannabis. Conclusion Allegation Four: VA1 provided information to this investigator and the LEO that on multiple previous occasions, the SP gave VA1 marijuana while the SP worked at the facility and the SP did not provide information regarding the allegation. The SP’s actions of providing marijuana to VA1 was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of the facility’s Drugs and Alcohol policy. However, given VA1 was over the age of 21 years old and there was no information in his/her plans about maintaining sobriety, there was not a preponderance of the evidence whether the SP failed to provide reasonable and necessary care to VA1. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The SP no longer worked that the facility. VA2 was reimbursed $40 and $14.43 respectively. All staff persons were retrained on maltreatment policies. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.
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