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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: 1089816-SUD (Substance Use Disorder) Investigator(s): Lindsay Arth 651-431-6537 Lindsay.Arth@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) touched a vulnerable adult’s (VA1’s) genital area, “slapped” VA1’s buttocks, and sent VA1 text messages that were sexual in nature. There were also concerns that the SP interacted in a similar manner with three other vulnerable adults (VA2, VA3, and VA4). Date of Incident(s): Ongoing prior to February 20, 2026 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 February 26, 2026; from documentation at the facility; and through eight interviews conducted with VA1, VA2, two facility clients (C1 and C3), a facility supervisory staff person (P1), and three staff persons (P2, P3, and P4). VA3 met with this investigator and said that s/he “did not want [his/her] name brought up,” did not know why s/he was involved, and declined to provide further information. Additionally, an interview was scheduled with a staff person (SP) but at the prearranged time, the SP did not answer this investigators call and did not return subsequent messages. Attempts were also made via phone, email, and U.S. mail to contact and interview VA4, and via phone to contact and interview a facility client (C2) but the attempts were not successful and neither VA4 nor C2 responded. The facility provided residential treatment services for individuals with substance abuse disorders. The clients typically shared a bedroom with one or two other clients. However, some of the rooms, including VA1’s, had dividers in them to separate each other’s beds. The cafeteria had an accordion wall which separated the room into two sides. There were cameras in some of the main areas of the facility but none in the client bedrooms or hallways. VA1 was diagnosed with anxiety and post traumatic stress disorder. VA2’s Treatment Plan said that VA2 wanted to focus on his/her mental health and talk to “trusted people.” VA4 was diagnosed with bipolar disorder, generalized anxiety disorder, and post traumatic stress disorder. P1; an email from VA1 to P1 dated February 19, 2026; texts between the SP and VA1; the Internal Investigation Report; and the Critical Incident Report dated February 16, 2026, provided the following information: · On February 18, 2026, a staff person (P5) told P1 that C2 “overheard” concerns that the SP was “inappropriate” with VA1. Additionally, C2 “thought” that the SP went into VA1’s bedroom and had oral sex with VA1 and “groped and kissed” VA1 and also did so in areas throughout the facility that did not have cameras. · P1 then tried to talk to VA1 but VA1 was initially “afraid” to talk and thought that s/he was in “trouble.” However, at some point after, VA1 spoke to P1 and told him/her that the SP made “sexual advances” towards him/her and engaged in “inappropriate texting,” including “sexual suggestions” with VA1. VA1 provided P1 text messages between him/her and the SP and P1 (and this investigator) “confirmed” it was the SP’s phone number in the texts. P1 said that there were “a lot of sexual comments” between the SP and VA1 in the text messages, including the SP stating that s/he would like to “be in [VA1’s] bed.” The text messages that VA1 provided to P1 did not have dates but showed that some were sent on a “Tuesday.” The text messages showed: o On an unknown date, the SP wrote, “It’s so hard pretending to ignore you at work when all I wanna [sic] do is talk to you, touch you, be near you.” The SP also told VA1 that s/he was not working because s/he was under “investigation.” The SP told VA1 not to say “anything about you knowing.” The SP asked VA1 if “they talked to you at all or did you hear anything?” The SP told VA1 that s/he “hoped” that VA1 did “not get in trouble too” and that s/he was “so worried.” At 6:50 p.m., there was a missed call but it was unknown if the SP or VA1 made the call. o On an unknown date, VA1 told the SP that they could “interact” but not to be “flirty” so it “did not look like [the SP] was targeting [VA1] only.” The SP responded and said, “Right right yes [sir/mam].” The SP told VA1 that s/he was “just sitting here thinking bout ya…wishing I could go hop in your bed!” The SP also said that s/he was “thinking” and “day dreaming” about VA1 “a lot.” o The SP told VA1 that they “might be able to sneak for a minute tonight” because another staff person (P7) was a “total flake” and “not observant at all.” The SP said, “You know what I’d like to do?” VA1 said that s/he “can’t fucking wait” and had been “fantasizing” about the SP. o The SP told VA1 that s/he had “never” done anything similar prior and thought s/he was going through a “midlife crisis” and that VA1 put “some sort of spell” on him/her. o The SP said that s/he “wished” VA1 were in bed next to him/her. VA1 said that s/he had a “low key panic attack when [s/he] woke and didn’t see [the SP].” o The SP said that s/he “really cared” about VA1 and wanted the “best” for him/her. o VA1 told the SP that s/he “hated the smell” of cigarettes and asked the SP for a vape. VA1 said that s/he “wanna [sic] be smelling like ts [this shit] and trynna kiss u I be embarrassed.” (Note: There was no information that the SP responded to this.) · VA1 also told P1 that on February 16, 2026, between 6 and 8 a.m., the SP came into his/her bedroom and woke VA1 by rubbing VA1’s chest and “attempting” to reach for his/her genitals. The SP also gave VA1 a sweatshirt. · VA1 was “pretty upset” with the SP and said that the incident caused him/her “emotional turmoil” and “anxiety” and s/he felt “powerless.” VA1 also said that the SP’s conduct was “unsolicited, inappropriate, and caused [VA1] to feel unsafe and uncomfortable.” · At some point, P3 told P1 that VA4 told him/her that the SP came into his/her bedroom during rounds and was “acting weird” and tried to “seduce” VA4 with his/her “words” but the SP “never touched” VA4. P1 attempted to talk to VA4 but VA4 did not want to “talk to [P1] about it.” · A staff person (P6) also told P1 that at some point, VA3 spoke to P6 in a “hypothetical” situation asking what would happen if a staff person touched a client “inappropriately.” P6 tried to get additional information from VA3 but VA3 did not provide any and said that s/he wanted to speak with a lawyer. P1 then spoke to VA3 who became “upset” and did not provide information. At some point, VA3 spoke to P2 and said that the SP “grabbed” his/her genital area and “slapped [his/her] ass.” However, at some point after that, VA3 told unknown clients to “stop” talking about the concerns because they were “ruining” the SP’s “life.” P1 said that VA3’s information was “very inconsistent” regarding what occurred with the SP. · VA2 also said that at some point, the SP gave VA2 his/her phone number to “get together” when VA2 left the facility and the SP gave VA2 $10 for cigarettes. At some point, VA2 asked the SP to be woken at 6 a.m. and when the SP did so, s/he touched VA2’s leg to wake him/her. · The SP “denied all the allegations.” The SP said that s/he watched “some videos” with a “group” of clients in the cafeteria but “that was all it was.” The SP touched clients on their arms or backs to be “reassuring” and said that s/he was a “touchy person.” The SP “did not know” if s/he touched a client’s chest. · Once the facility became aware of the incidents, they reviewed video footage but did not observe anything concerning. · P1 had not worked with the SP and was not aware of any other concerns. The SP had not worked at the facility long (since December 2025). The SP typically worked with P4 who would have told staff persons, including P1, if s/he had concerns. · Staff persons needed to go into clients bedrooms to wake them because staff persons could not see all the client beds from the doorways. However, staff persons should not touch clients to wake them. Staff persons were trained not to have any “physical contact” with clients. Staff persons were “forbidden” to give their phone numbers to clients and were not to share personal information with clients or give money or other things to clients. VA1 provided the following information: · Initially, VA1 had no concerns with the SP and described the SP’s interactions as a typical staff to client relationship. However, at some point, “out of nowhere,” the SP became “aggressive” in his/her interactions with VA1 including that “at first,” the SP made “eye contact” with VA1 which “weirded [VA1] out.” Then, around February 14 or 15, 2026, the SP’s interactions became “physical,” including that the SP “pushed” his/her body against VA1’s and “grabbed” VA1’s genital area and “forced” VA1 to kiss him/her. VA1 said that the SP “forcibly” kissed him/her on three occasions, including a Saturday night, Sunday night, and on a Monday. The SP did this in areas without cameras or in areas where there were “blind spots” with the cameras, including in the facility hallway. At times, the SP also woke VA1 by “feeling [him/her] up,” including on VA1’s chest. VA1 described the SP’s “behaviors” as “so bold.” The SP’s interactions caused VA1 to stay in his/her bedroom to “avoid” the SP. VA1 denied that s/he or the SP had sexual intercourse or oral sex. · VA1 did not think that anyone would believe what the SP was doing unless VA1 “got [evidence] in writing” via text message. VA1 took his/her “power back” and “played along” and on a “Monday morning,” VA1 was able to get the SP’s phone number to “get more evidence.” VA1 then began texting with the SP including asking the SP for a vape and at some point after, the SP brought VA1 two vapes. The SP also gave VA1 a sweater. The SP also talked about “hopping” in VA1’s bed. At some point, the SP sent VA1 a text message stating that staff persons had “found out” and for VA1 “not to say anything.” · VA1 said that other clients were trying to “profit off [his/her] trauma” and were “lying ass people.” VA2 said that on an unknown date, the SP gave VA2 his/her phone number and told VA2 that they could “hang out sometime.” However, VA2 did not contact the SP and “threw away” his/her number. The SP also brought VA2 a candy bar and gave VA2 $10 for cigarettes but told VA2 to not let staff persons see because the SP could “get in trouble.” The SP also talked about his/her family members, including where s/he grew up and that they were going out of town, VA2 described the SP as “kind of flirtatious.” At some point, VA2 asked to be woken at 6 a.m., and at 6 a.m., the SP came into VA2’s room and “shook” VA2’s leg. The SP did not do similar with VA2’s roommates. VA2 said that the SP’s interactions weren’t “bad” but “felt odd.” VA2 also heard “rumors” that the SP “screwed” one of the clients but VA3 told the clients not to say anything to staff persons because s/he and other clients were going to “sue” the facility. P2 and the Critical Incident report dated February 19, 2026, provided the following information: · On February 19, 2026, at 2 p.m. while doing rounds, VA3 told P2 that s/he had an “uncomfortable” incident with the SP and that “one night,” the SP “grabbed” his/her genital area while VA3 was in his/her bedroom. VA3 also said that at some point, C1 and C3 observed the SP “slapping [VA3’s] ass.” VA3 told P2 that s/he did not want to provide information to “anyone else” until s/he spoke to his/her lawyer. · At some point after, VA3 was overheard telling other clients not to “accuse” the SP of “inappropriately touching them.” · At some point, C2 told P2 that s/he was in the hallway during the night and saw the SP “sneak into” clients rooms, including VA1’s. · P3 did not work with the SP so did not observe the SP’s interactions with the clients. P3 and the Critical Incident Report dated February 19, 2026, provided the following information: · On an unknown date, VA2 told P3 that the “overnight” staff person, who no longer worked at the facility (later determined to be the SP), gave VA2 his/her phone number and also gave VA2 $10 for cigarettes and a candy bar. VA2 said that the SP told him/her that s/he left VA2 his/her number so that VA2 could text him/her when VA2 left the facility to “maybe hang out” and so that VA2 could “pay” the SP back. At some point, VA2 asked the SP to be woken at 6 a.m., and when the SP woke VA2, the SP touched VA2’s leg. The SP also talked to VA2 “often” in the cafeteria and the SP shared “personal information,” including that his/her family members were out of town. P3 said that VA2 was concerned about getting in “trouble.” · At some point, VA4 talked to P3 and said, “You’ve obviously heard about what is going on?” VA4 then told P3 that the SP “obviously raped” VA1 and that the SP and VA1 engaged in oral sex and sexual intercourse, and that the SP “did the same thing” to him/her. P3 asked VA4 for additional information and VA4 said that at some point, the SP came into his/her bedroom and “tried to do the same thing to me.” the SP made VA4 “uncomfortable” and “tried to seduce” VA4 with what the SP “was saying.” The SP got “close” to VA4 and VA4 told the SP to “get out” of his/her room. VA4 felt “uneasy” about the incident and P3 said that VA4 appeared “scared.” VA4 told P3 that s/he had similar things happen to him/her at prior programs and that the incident with the SP reminded him/her of that. · P3 did not work with the SP so did not observe any interactions between the SP and clients. Staff persons were trained not to have sexual contact with clients or have any relationship with them for two years after they left the facility. The facility was a “no touch” facility and staff persons were not to share personal information with the clients. P4 provided the following information: · On February 19, 2026, the SP sent P4 a text message stating that s/he did “something wrong” and was “getting fired over a dumb report.” P4 then called and spoke to the SP who said that s/he thought the concerns were regarding the SP being “alone” with the clients, including going with clients to get food from another building, or “pushing” VA1 by his/her chest to get VA1 out of the staff office. · At some point, there was a “rumor” at the facility that VA3 said that VA1 told other clients to say that they were “also sexually assaulted” by the SP to make VA1’s “case better.” · P4 did not observe any concerns with the SP’s interactions with the clients but said that the SP would often touch the clients, including on their shoulder or “tapping” the back of their arms, but nothing that was in a sexual manner. However, staff persons were trained to “never” touch clients. Additionally, at times the SP would be “gone” for an “extended period of time” but P4 thought that the SP was cleaning or doing other work related tasks throughout the facility. On three occasions, P4 saw the SP in the cafeteria behind a “divider” talking to VA1 and another client (C4) but there was nothing “nefarious” that P4 observed. The SP told P4 that s/he was “talking” or making food. · At times, due to staffing, the SP was the only staff person at the facility during the overnights. · Staff persons were trained not to give clients their phone numbers and P4 was not aware of the SP giving his/her phone number to any client. C1 and C3 did not have any concerns with the facility or with staff persons interactions with the clients. C1 was not aware of any staff person giving their phone numbers to the clients. C1 and C3 shared a room with VA1 and were not aware of any staff person having sexual contact with a client and not aware of any staff person touching a clients legs, touching their buttocks, or touching a client in his/her bedroom. The Personal Relationship Staff and Clients said that staff persons were not to spend money on a client or have any “intimate interaction.” All staff persons were to be aware of the “imbalance of power” in relationships between staff persons and clients. Any relationship between staff persons and clients was “strictly prohibited.” Additionally, contact or communication between staff persons and client’s outside of the clients treatment plan that the employee seeks to conceal was not allowed. Physical contact with clients was “strictly limited” to what was necessary for the provision of appropriate medical care. Additionally, except for handshakes, any contact, including gestures of comfort, “casual” touch, hugs, or other physical contact was prohibited. Facility documentation showed that the SP, P1, P2, P3, and P4 were trained on Professional Ethical Boundaries and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Regarding Sexual Abuse: C2 told P5 that s/he “overheard” concerns that the SP and VA1 had oral sex and that the SP “groped” VA1. VA4 also told P3 that the SP and VA1 had oral sex and sexual intercourse. However, VA1 told this investigator that s/he and the SP did not have oral sex or sexual intercourse but that the SP “rubbed” his/her chest and “grabbed” his/her genital area. Additionally, the SP kissed VA1 on three occasions. P1 said that VA1 was “pretty upset” with the SP and VA1 told P1 that the incident caused him/her “emotional turmoil” and “anxiety.” Although the SP did not provide information for this report, P1 stated that the SP denied the allegations when they spoke. Although no client or staff person observed the aforementioned concerns between the SP and VA1, the SP had reason to minimize his/her actions for fear of repercussions and VA1 had text messages that were determined to be from the SP because of the phone number and showed that the SP told VA1 that s/he wanted to “touch” VA1 and be in VA1’s bed. The text messages also showed that the SP told VA1 that they “might be able to sneak away” and asked VA1, “You know what I’d like to do?” to which VA1 responded s/he “can’t fucking wait” and that s/he had been “fantasizing” about the SP. The SP also told VA1 not to say “anything about you knowing.” Therefore, given that the text messages corroborate VA1’s account, it was determined that VA1’s account was more credible than the SP’s. Therefore, there was a preponderance of the evidence that the SP had sexual contact with VA1. 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). VA4 told P3 that the SP “tried” to do similar to him/her but that s/he told the SP to get out of his/her bedroom. VA3 also told P2 that the SP “slapped [his/her] ass” and “grabbed” his/her genital area but VA3 declined to provide information to this investigator and said that s/he “did not know why [s/he] was involved.” Although VA3 told P2 that C1 and C3 observed this, C1 and C3 each denied seeing this. P4 also said that there was a “rumor” that VA3 said that VA1 told other clients to say that they were “also sexually assaulted” by the SP to make VA1’s “case better.” The SP did not provide information to this investigator but denied the allegations to the facility. Given this and without further information, it was not determined whether the SP had sexual contact with VA3 and/or VA4. 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). Regarding Neglect: VA2 said that the SP “shook” his/her leg when waking VA2, gave VA2 his/her phone number, and gave VA2 money, which were violations of the facility policies and procedures and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. In addition, the SP’s aforementioned interactions with VA1 including the text messages were also violations of the facility policies and procedures and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services VA1 and VA2 were at the facility receiving services for their respective diagnoses and it was reasonable that each would continue to need supports to develop and maintain the necessary life and social skills to maintain sobriety. The SP’s interactions with VA1 and VA2 likely hindered VA1’s and VA2’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide each with therapeutic services, both now and in the future. Therefore, there was a preponderance of the evidence that the SP’s interactions with VA1 and VA2 were detrimental to VA1’s and VA2’s ongoing mental health which were a failure to provide VA1 and VA2 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). VA4 also told P3 that the SP tried to “seduce” him/her with “words.” However, VA4 did not provide information for this investigation and without additional information, it was not able to be determined what occurred between the SP and VA4. Therefore, there was not a preponderance of the evidence whether neglect occurred in regards to VA4. 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). 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 the Professional Ethical Boundaries and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for the maltreatment of VA1 and VA2. 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 “serious” and “recurring” maltreatment. The SP was responsible and the recurring sexual abuse of VA1 and neglect of VA1 and VA2. The SP was disqualified from a direct contact position. 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. Staff persons completed a “boundaries refresher training.” 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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