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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: 1069234-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden Thomas.C.Nixon@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual intercourse with a vulnerable adult (VA) more than once. Date of Incident(s): Ongoing between August/September and November 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 November 26, 2025; from documentation at the facility and law enforcement records; and through six interviews conducted with the VA’s guardian (G), the VA’s case manager (CM), the VA’s healthcare professional (HCP), a supervisory staff person (P1), an administrative staff person (P2), and the SP. The VA provided information to a law enforcement officer (LEO), which was included in this report. The VA’s support plans, including Individual Abuse Prevention Plan, stated the following: · In 2023, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included traumatic brain injury and partial blindness. · The VA required some level of assistance with most of his/her activities of daily living. The VA hoped to increase his/her independence and move to a home closer to his/her family. The facility provided the VA with at least one staff person 24-hours a day. · The VA was susceptible to sexual abuse from others. Due to the VA’s visual impairment, s/he might not see when someone was approaching and might struggle to protect him/herself. Staff intervened in potentially dangerous situations and reported concerns on the VA’s behalf. “[The VA] has the ability to communicate concerns to [his/her] team if needed.” The facility was a single-family home where the VA lived with housemates. The VA’s bedroom was down a short hallway from the main living area. The G, the CM, the HCP, P1, and P2 each said that the VA was a reliable reporter of information. The VA told each of them, separately, that s/he had sexual intercourse with the SP three different times in the VA’s bedroom. A law enforcement report stated the following: · The VA told the LEO that s/he and the SP had sexual intercourse with penetration three times on the VA’s bed in the VA’s bedroom. The most recent instance occurred on November 6 or 7, 2025. During each instance and after, the VA felt “uneasy” and believed the sexual contact was “not right” because the SP was a staff person. On November 10, 2025, the VA told P1 and said that s/he felt “uncomfortable” about the SP’s conduct. · The SP told the LEO that s/he worked five days a week between 3 and 10 p.m. and was typically the sole staff person during that time. The VA had a head injury, frequently repeated him/herself, and wanted to live independently someday. At least once, the SP and the VA kissed on the facility’s couch, and twice, they had sexual intercourse in the VA’s bed. Each instance occurred between 8:30 and 9 p.m., when the VA’s housemates were in their respective bedrooms for the night and not around. The sexual contact was “mutual and not forced.” “[The SP] expressed remorse and said [s/he] had decided [s/he] needed to leave (his/her employment at the facility) because of [his/her] feelings and the boundary concerns.” The facility’s Internal Review stated that the SP told P2 that s/he had sexual intercourse with the VA twice in the VA’s bedroom; this included penetration and occurred within the last 30-45 days, as of November 11, 2025. The SP said that s/he knew the VA was a “vulnerable adult” and that the sexual contact “wasn’t right.” “I made a wrong decision, and it shouldn’t have happened.” The SP told the DHS investigator that around July 2025, s/he and the VA started holding hands and talking a lot. The SP cared for the VA and gave him/her hugs. Around August or September 2025, the SP had “consensual” sexual intercourse with the VA in the VA’s bedroom; this included penetration, but without “protection” (contraception/barrier to prevent sexually transmitted infections). Between August or September and November 2025, they had sexual intercourse around three to four times in the VA’s bedroom. The SP said that the VA was subject to guardianship and could not make his/her own decisions. The VA had been in a coma prior to moving into the facility and his/her guardianship was appointed during that time. The VA sometimes repeated him/herself and struggled with his/her memory. The SP’s job duties included helping with the VA’s meals and medications. The VA did not have a history of saying “untrue things” about staff. The SP could not remember the facility’s training on staff-client relationships but said that s/he knew his/her sexual contact with the VA “was wrong.” Facility documentation stated that the SP received training on the VA’s support plans, including Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: The VA and the SP provided consistent information that they had sexual intercourse with penetration in the VA’s bed at least three different times between August or September and November 2025. The VA said that s/he felt “uneasy” and “uncomfortable” and believed the sexual contact was “not right” because the SP was a staff person. The SP said, “I made a wrong decision, and it shouldn’t have happened.” Given that the SP was a staff person at the facility and the VA was a person receiving services at the facility, there was a preponderance of the evidence that the SP’s conduct included sexual contact and penetration with the VA. 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 responsible for the VA’s care and supervision. The SP received training on the VA’s support plans, including Individual Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. 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 for which the SP was responsible was “recurring and serious” maltreatment. The SP had sexual intercourse with the VA at least three different times between August or September and November 2025. 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 by the SP. 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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