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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: 1070661-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson/Alice Percy Minnesota Department of Human Services 651.431.6578 Suspected Maltreatment Reported: It was reported that a staff person (SP) touched a vulnerable adult’s (VA’s) genital area during the night. It was also reported that on multiple occasions the SP attempted to touch the VA’s genital area when the SP drove the VA in the facility’s van. The SP often asked the VA to touch the SP’s genital area, but the VA declined to do so. Date of Incident(s): Ongoing, prior to December 14, 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 December 30, 2025; from documentation at the facility and law enforcement records; and through six interviews conducted with a facility staff person (P1), two supervisory staff persons (P2 and P3), the SP, the VA, and the VA’s guardian (G). The VA enjoyed taking walks, riding bike, playing games, swimming, going on community outings, and spending time with his/her family members. The VA’s diagnoses included pervasive developmental disorder, oppositional defiant disorder, anxiety disorder, mild intellectual disabilities, paraphilia, and attention-deficit hyperactivity disorder. The VA earned money by mowing lawns, raking leaves, and shoveling snow. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to sexual abuse. Due to a lack of understanding, the VA might not have the ability to recognize when s/he was in an abusive situation. The facility’s Progress Notes dated December 14, 2025, provided the following information: · [The VA] reported to [P1] that [the SP] touched their private parts in the middle of the night. [The VA] stated, I woke up in the middle of the night to something touching my private area and I put my hand there to see if it was a spider or something and it was a hand, and I jumped because I was scared and I looked up and it was [the SP].” [The VA] went on to say [the SP] appeared to get upset when [the VA] yelled cause they were scared.” · [P1] asked [the VA] if this has happened more than one time. [The VA] stated, “[The SP] will also try to reach for my private area in the car while they are driving and they almost went into the ditch on Saturday, (December 13, 2025).” [P1] asked if [the SP] has done that in the car more than once. [The VA] stated, “[The SP] does that almost every time we go anywhere. · [The VA] also reported that [the SP] will often ask [the VA] to touch [the SP’s] private area. [The VA] reported that they decline each time. The VA provided the following information: · On one occasion, the VA was sleeping in his/her bed, when the SP entered the VA’s bedroom, pulled the blankets off the VA and tried to pull down the VA’s pants. The SP did not say anything during the incident. The VA told the SP to leave his/her bedroom. The VA then told another staff person about the incident. · On another occasion after the VA told P1 about the incident in the VA’s bedroom, the VA and the SP were both in the hot tub at the YMCA. The SP “came under the water” and tried to touch the VA’s genital area. The SP tried to “go through [the VA’s] shorts underneath” to touch the VA’s leg and genital area. The VA moved to the other side of the hot tub. P1, P2, and P3 provided the following information: · P2 stated that on December 14, 2025, from 8 a.m. to 2 p.m., the SP worked at the facility. That was the SP’s last work shift at the facility. P1 worked at the facility from 2 to 10 p.m. · P1 stated that during his/her work shift, the VA told P1 about the SP trying to touch the VA’s genital area while the VA was sleeping and also on two or three occasions when they were in the facility van. After the VA told P1 about the incidents, the VA seemed relieved and like “a weight lifted off [his/her] shoulders.” P2 stated that P1 talked to P2 about what the VA told him/her. The SP did not work at the facility after the VA talked to P1 about the incident. · P2 stated that the VA sometimes became upset with the SP because the SP pushed the VA to do things. P3 stated that sometimes the VA liked the SP and other times, s/he did not. The VA did not like to “be held accountable” by the SP and sometimes “tried to get staff in trouble.” · P3 did not have concerns about the SP’s interactions with the clients. P3 stated that the VA typically went into his/her bedroom alone and locked the door. The SP did not have a key to the VA’s bedroom door and would have to borrow a key from P3 or another staff person if s/he needed to enter the VA’s bedroom. The SP would typically only enter the VA’s bedroom to clean it and at those times, there would be another staff person with him/her. · P2 stated that typically two staff persons worked at the facility, except for brief periods during the day. One of the staff persons would work with the VA and the other staff person would work with the other clients. The VA and the SP went to the YMCA together on December 2 and 5, 2025, at 7 p.m. The YMCA video recordings for those dates did not show any contact between the VA and the SP in the hot tub. The SP provided the following information: · The SP stated that s/he had not worked a night shift at the facility for at least three months. At times, the SP would work from 8 a.m. until 10 p.m., but did not “do” night shifts. There were typically two staff persons working at the facility, except from 8 to 10 a.m. and 9 to 10 p.m., when there was usually only one staff person. The VA and another client (C) typically received their evening medications between 10 and 11 p.m., prior to going to bed. The VA typically went to bed after the SP’s work shift ended. The SP tried to hold the VA accountable to shower and do his/her daily tasks. · The SP never did any “sexual things” with any of the clients. The SP might have given the clients, including the VA, a “high five” or a “side hug” as/she asked how their day was going. The SP did not touch the VA’s genital area except for one occasion when s/he had to apply bacitracin ointment to the VA’s anal area as prescribed. The SP believed another staff person was present at the time. · Approximately one month ago, the SP and the VA were each in the hot tub at the YMCA, but remained on opposite sides of the hot tub and the SP did not touch the VA. The SP believed there were video cameras near the hot tub. The facility’s work schedule provided the following information: · On December 3, 4, and 5, 2025, the SP worked at the facility from 4 to 10 p.m. · On December 6, 2025, the SP worked at the facility from 4 to 9 p.m. · On December 7, 2025, the SP worked at the facility from 2 to 10 p.m. · On December 10, 2025, the SP worked at the facility from 8 a.m. to 2 p.m. · On December 11, 2025, the SP worked at the facility from 2 to 10 p.m. · On December 12, 2025, the SP worked at the facility from 8 a.m. to 2 p.m. · On December 13 and 14, 2025, the VA worked at the facility from 8 a.m. to 4 p.m. · In November 2025, the SP did not work past 10 p.m. on any work shift. The G stated that the VA received “pretty good care” at the facility. The VA was sometimes hard to understand and became frustrated when talking, but “would be fine” if s/he was calm. The facility’s Boundaries policy stated that the staff persons were not to engage in any emotional, physical, or sexual relationships with clients and were not to engage in any sexual acts or sexual behaviors with clients. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: On December 14, 2025, the VA told P1 that the SP attempted to touch the VA’s genital area during the night while the VA was in his/her bed. The VA also told P1 that the SP attempted to touch the VA’s genital area when they were driving in the facility’s van. The VA later provided information that the SP attempted to touch the VA’s genital area in a hot tub at the YMCA. The SP stated that s/he did not touch the VA’s genital area at any time except for one occasion when s/he applied bacitracin ointment to the VA’s anal area as prescribed. Facility documentation showed that the SP did not work any overnight shifts during November or December 2025. The YMCA’s video recordings did not show any physical contact between the VA and the SP in the hot tub. Information was provided that the VA sometimes became upset with the SP because the SP held the VA accountable to do his/her daily tasks. Although the VA provided consistent information that the SP tried to touch the VA’s genital area on several occasions, given that the SP denied trying to touch the VA’s genital area; that the SP did not work any overnight shifts at the facility in November or December 2025, and would not be at the facility when the VA was sleeping in his/her bed; and that the video recordings from the YMCA did not show any physical contact between the VA and the SP in the hot tub, there was not a preponderance of the evidence as to whether any sexual contact between the VA and the SP occurred. 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 and determined that the facility’s policies were adequate, but were not followed by the staff persons. After the incident, all of the staff persons were retrained on the facility’s policies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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