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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: 1104736-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth/Beth Virden Minnesota Department of Human Services Office of Inspector General Licensing Division PO Box 64242 Saint Paul, Minnesota 55164-0242 651-431-6537 lindsay.arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) grabbed a vulnerable adult’s (VA) buttocks and made sexual comments. Date of Incident(s): Between October 7 and 17, 2025; other dates 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 (c); and subdivision 17, paragraph (a): 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. 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 November 5, 2025; from documentation at the facility and law enforcement records; and through four interviews conducted with facility staff persons (the SP, P1, and P2), and a supervisory staff person (P3). Attempts were made by telephone and email to contact and interview the VA, but the VA did not respond by the completion of this investigation. Law enforcement records included interviews with the VA, a staff person (P4), and a supervisory staff person (P5), which were included in this report. In July 2025, the VA moved into the facility seeking sobriety and recovery services relating to his/her substance use disorder. The facility provided the VA with residential treatment and individual and group therapy. The VA did not have a history of being susceptible to abuse by others. The VA provided the following consistent information to P1, P3, and a law enforcement officer (LEO) each on different dates: · Between July and October 20, 2025, the SP worked in the kitchen and mainly interacted with clients, including the VA, during mealtimes. More than once, the SP told the VA that they should meet up in the community when the VA was on a day pass from the facility or after the VA completed treatment and moved out of the facility. The VA did not meet up with the SP in the community and had no intention of meeting up with the SP after s/he completed treatment. · One time, on an unknown date, the VA walked through the facility wearing a robe and the SP made a comment about wishing s/he knew what was under the VA’s robe. · More than once, the SP looked “up and down” at the VA’s body while licking his/her lips and saying, “Mm.” At least once, the SP looked at the VA’s clothed groin area and said, “I bet that tastes good.” · One time, there was another client nearby when the SP made an unspecified comment to the VA. The VA later asked the client if s/he heard what the SP said but they did not. This was the sole time the SP said something that might have been within earshot of someone else. · Between October 7 and 17, 2025, the clients’ ice machine was broken and the SP let clients store their personal food items in the kitchen’s freezer. The VA asked to put a bag of candy in the freezer and the SP led the VA into the back of the kitchen to the freezer. The VA then turned to face the freezer with his/her back to the SP and while doing so, the SP said something about there not being any cameras in the kitchen and then placed both of his/her hands on the VA’s buttocks and “forcefully grabbed … a lift-up, push grab.” The VA “froze” (did not immediately move) but then walked out of the kitchen feeling “dirty and gross.” The VA did not immediately tell anyone what happened and instead stayed in his/her bedroom to avoid seeing the SP. The VA said that s/he stopped going to breakfast unless there were other clients around. P1-P3 and a law enforcement report provided the following information: · P3 said that on October 20, 2025, during the afternoon, s/he approached the VA in the VA’s bedroom. P3 said that the “last few days something seemed off” with the VA. The VA previously told staff that s/he was sick and so was isolating in his/her bedroom and not attending groups. It was not typical for the VA to skip groups because until this point, the VA had been regularly attending all groups. P3 told the VA that s/he needed to start attending groups. The VA said that s/he would but asked to speak privately with P3 the next morning about something unspecified. P3 then left work for the day with a plan to meet the VA the next morning. · P1 and P5 each said that the VA routinely attended groups but, on an unspecified date, stopped going to groups and was “hiding” in his/her bedroom and skipping breakfast. · P1 said that on October 20, 2025, around 7 p.m., the VA asked to speak privately with P1. The VA appeared “teary-eyed and nervous” and at that time told P1 the aforementioned information about the SP’s conduct, including that the SP grabbed the VA’s buttocks by the freezer. P1 then called P3. · P3 said that on October 21, 2025, during the morning, s/he spoke with the VA, who provided the aforementioned information about the SP’s conduct, including that the SP grabbed the VA’s buttocks by the freezer. Later that same day, P3 called the SP and told him/her that there was an allegation about the SP’s conduct and that the SP should not return to work until an investigation was completed. P3 did not tell the SP any details about the allegation. · The law enforcement report included statements from P4 and P5. P5 said that on October 21, 2025, at an unstated time, the SP called him/her and resigned from his/her employment at the facility. During this call the SP “made a comment about grabbing one of those bitch’s asses,” and “also commented on why would [s/he] want to lick one of them hoes ass?” P5 said, “[The SP] said this stuff to me before [the SP] even knew what the allegation was as far as I know.” · P1, P2, P3, P4, and P5 each said that the VA was not someone who would fabricate an allegation and had no history of providing inaccurate information about staff conduct or stating other staff grabbed him/her. There was no known conflict or reason the VA might want to get the SP in trouble. It was “out of character” for the VA, who historically stayed to him/herself and completed his/her programming while “flying under the radar.” · P1 said that clients were allowed in the kitchen with the SP’s permission and supervision. · P1, P2, and P3 each said that staff were prohibited from engaging in personal or sexual relationships with clients while they were at the facility and for at least two years after the client discharged from the facility. The SP provided the following information: · The SP said that s/he last saw the VA on October 20, 2025, when the VA left the building with his/her significant other. The SP said that s/he later heard from an unidentified person that when the VA returned to the facility on October 20, 2025, s/he had relapsed and consumed alcohol. [Note: Facility documentation stated that the VA’s urinalysis tested positive for alcohol on October 4, 2025, which the VA self-reported to staff and was receptive to programming to address the incident. There was no information of additional relapses, including on or around October 20, 2025.] · The SP said that s/he did not grab any client’s buttocks and/or make sexual statements to any client. Rather, the clients routinely made “nasty comments” to the SP and the “main one” to do this was the VA. · The VA made “suggestions” (no information of what this entailed) about the SP’s hat and at least once, the VA bent over in front of the SP, which the SP told P3 about. [Note: P3 said that the SP told him/her that unidentified clients, not specific to the VA, said “perverted things” to the SP. The SP did not tell P3 about the VA bending over in front of the SP.] · The SP said that the facility’s training included that staff were not allowed to have personal relationships with clients. · The SP did not know why the allegations were made against him/her. The facility’ Policy and Procedure Manual stated, “It is the policy that no employee is to engage in sexual contact or romantic relationship with current or former clients (a person that was enrolled in any [facility] program) for a period of two years.” Staff were also prohibited from engaging in harassment and/or activities perceived as threatening. Facility documentation stated that the SP and P1-P5 received training on the facility’ Policy and Procedure Manual and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: The VA provided consistent information to P1, P3, and the LEO that the SP made comments about the VA’s body and at least once grabbed the VA’s buttocks. The VA said that the SP’s conduct made him/her feel “dirty and gross” and that following the SP grabbing the VA’s buttocks, the VA isolated in his/her bedroom, stopped attending groups, and skipped meals to avoid seeing the SP. Although the SP denied the allegations, the VA did not have a history of providing inaccurate information and did not have a history of making such statements. In addition, P5 said that on October 21, 2025, at an unstated time, the SP called him/her and resigned from his/her employment at the facility. During this call, “[The SP] made a comment about grabbing one of those bitch’s asses,” and “also commented on why would [the SP] want to lick one of them hoes ass?” P5 said, “[The SP] said this stuff to me before [the SP] even knew what the allegation was as far as I know.” More than one person noticed the VA started isolating and stopped attending groups, which was not typical of him/her, during the time when the VA said the incidents occurred. Given that the VA did not exaggerate or embellish the allegations and instead provided consistent information to three different people; and that when P5 talked to the SP, the SP “made a comment about grabbing one of those bitch’s asses . . . before [the SP] even knew what the allegation was as far as I know,” it was determined the VA’s account was more credible than the SP’s account. Regarding sexual abuse: Given that the SP made more than one sexual comment to the VA and that the SP grabbed the VA’s buttocks when the VA was standing at the freezer with his/her back turned to the SP, there was a preponderance of the evidence that the SP’s conduct included sexual contact, which as defined by Minnesota Statutes, includes the intentional touching of the intimate parts with sexual or aggressive intent, including the buttocks. 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). Regarding neglect: The VA was at the facility seeking sobriety and recovery services relating to his/her substance use disorder. The VA had been regularly attending groups and programming up until the incident when the SP grabbed the VA’s buttocks. At that point, the VA began isolating in his/her bedroom and missing groups and meals to avoid seeing the SP, which likely impacted the VA’s sobriety and recovery efforts. Given that the VA had a history of a substance use disorder, it was reasonable that the VA would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions not only impacted the VA’s time at the facility but will likely hinder his/her ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide him/her with therapeutic services, both now and in the future. Therefore, there was a preponderance of the evidence the SP’s interactions with the VA were detrimental to the VA’s ongoing mental health and were a failure to provide the VA with reasonable and necessary care or services. 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. The SP was responsible for the VA’s care and supervision. The SP received training on the Reporting of Maltreatment of Vulnerable Adults Act and the facility’s Policy and Procedure Manual. The SP was responsible for maltreatment of the VA. 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 and neglect for which the SP was responsible was not recurring because the SP’s comments to the VA and the SP touching the VA’s buttocks was a considered a single incident but met the definition of “serious” maltreatment. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The facility did not determine a need for additional training or corrective action. The SP no longer worked at the facility. 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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