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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: 1110565-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy Heidi.Murphy@state.mn.us 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) had a vulnerable adult (VA) sit on the SP’s lap, sucked on the VA’s nipples, and digitally penetrated the VA’s intimate parts. Date of Incident(s): November 14-16, 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 4, 2025; from documentation at the facility, law enforcement records, and medical records; and through ten interviews conducted with four facility staff persons (SP, P1, P2, and P4), two facility supervisory staff persons (P3 and P5), the VA’s guardian (G), a health care professional not associated with the facility (HP), a community person (CP), and the VA. The facility was a rambler style single family home in a residential neighborhood with a finished basement. The main level consisted of three bedrooms, two living rooms, a kitchen, a dining room, two bathrooms, a laundry room, and a small room used as a second eating area. The basement consisted of the VA’s bedroom, an office, a storage area, and a family room. The VA’s diagnoses included phenylketonuria (PKU), mild cognitive impairment, and developmental delay. The VA enjoyed participating in Special Olympics, going shopping, and doing arts and crafts. The VA’s plans stated that in the past, the VA “touched people that may not want to be touched” and did not recognize personal boundaries. The VA “may not always be truthful or may not tell the entire truth.” The VA provided the following information: · On November 14-16, 2025, (Friday through Sunday) the SP worked the overnight shifts at the facility. On Friday night just prior to 8 p.m., the SP helped two residents with their nightly hygiene tasks. Once the other residents went to bed, the SP sat at the kitchen table with the VA. The SP had the VA sit on his/her lap and picked the VA up off the ground. · On both Saturday and Sunday night again after the other residents went to bed, the SP had the VA sit on the SP’s lap, picked the VA up off the ground, and carried the VA to the back living room. The SP and the VA sat on the couch and the SP lifted the VA’s shirt up, sucked on the VA’s nipples and breasts, and put the SP’s finger in the VA’s “private area.” The SP asked the VA to suck on the SP’s nipples, but the VA refused. Around 9:30 p.m., the VA “got tired” and got up and went down to bed ending the incidents. The SP told the VA to keep it a “secret.” · During the investigation with this investigator the VA provided some conflicting information. The VA initially stated the SP was the only staff person working at the time of the incidents which occurred between 8-10 p.m. but the VA also stated that P1 worked until 10 p.m. The VA also provided various different accounts about when the incidents occurred stating the following: o s/he was still upstairs before going to bed when the incidents occurred o s/he was asleep downstairs and was awakened by someone entering the house upstairs, as the door made a “little sound” o that s/he went upstairs to get a snack o that s/he came upstairs to use the bathroom o (Note: It was unclear if each account was a different day or if the VA had some confusion about what had happened.) · The VA usually had a snack at 8 p.m. and did not usually go downstairs to bed until 9 p.m. The SP “always wanted [the VA] to keep [the SP] company” while the SP ate between 8 to 9 p.m. The CP provided the following information: · On November 21, 2025, the CP had a meeting with the VA in person and the G joined via phone. It was the first time the CP had met the VA. The G disconnected from the call and the CP asked the VA some general health and safety questions that included if the VA was fearful of someone touching him/her in a way that made the VA feel uncomfortable. The VA answered, “Well, there is one person,” and proceeded to tell the CP about the SP touching him/her in a sexual way. · The VA was “quiet and cautious to share” when talking to the CP. As the VA gave more details, the VA got more upset. The VA disclosed previous sexual trauma and the CP thought that talking about the incident with the SP was “triggering” for the VA. · The VA said the SP asked the VA to sit in his/her lap and then sucked on the VA’s breasts and touched the VA’s “private parts.” The VA said s/he stayed up later at night than the other residents and the incident(s) happened after the other residents went to bed. P1 provided the following information: · P1 worked on November 14, 2025, until 10 p.m., November 15, 2025, until 10 p.m., and worked the overnight shift on November 16, 2025, which started at 10:51 p.m. The VA was downstairs when P1 left on November 14 and 15. · Typically, staff persons gave residents snacks between 7-7:15 p.m. A staff person then assisted two of the residents with personal hygiene tasks, which took 20-30 minutes per resident. The other staff person cleaned the kitchen and living room. On November 14, 2025, the SP did the dishes when P1 assisted clients get ready for bed. Residents went to bed around 8 p.m. The VA was the first one to go to [his/her] room and “always” went downstairs around 8 p.m. The VA came upstairs to use the bathroom at times during the night. P1 never saw the SP and the VA in a space together after the other residents went to bed at any time. · P1 had no concerns with the SP’s interactions with the VA or any other residents. P1 only ever heard the SP and the VA talking about meals or how the VA’s day went. P1 did not think the VA was able to provide accurate information and stated that the VA had provided inaccurate information in the past. P2 provided the following information: · After the VA told the CP about the incident, the VA told P2 that when the SP worked the overnight shift, the SP waited for the other residents to go to bed and then had the VA sit on his/her lap, wrapped the VA’s arms around the SP’s neck, carried the VA to a living room in the back of the facility, put his/her mouth on the VA’s breast area, and touched the VA’s “private parts.” The VA also stated the SP was the only staff person working at the time. The SP told the VA to keep it a “secret,” but the VA did not like secrets and chose to tell someone. The VA told P2 that it was “scary,” and the VA did not want it to continue to happen. · The VA was not always truthful, but most incidents involved the VA not being truthful about taking food or eating food the VA was not supposed to have. The VA had a history of saying things about people that were found to be untrue but never anything as serious as this allegation. · P2 worked with the SP every other weekend and had no concerns with the SP or the SP’s interactions with the residents. On November 14, 2025, P2 worked during the day until 3 p.m. and was off on November 15-16, 2025. · When P2 worked the afternoon shift, one staff person assisted two residents with personal hygiene tasks before they went to bed. It took approximately seven to ten minutes to help each of the two residents with their nightly hygiene tasks. The second staff person cleaned up the facility. A third resident got him/herself ready for bed by him/herself. Sometimes the VA hung around the kitchen table or on the couch watching television after the other residents went to bed, then said goodnight and went to the VA’s room downstairs. Other times, the VA went downstairs while the other residents were going ready for bed. When P2 was at the facility, the VA was never upstairs past 8:30 p.m. · The SP and P1 would sit in the living room at the back of the facility after the cleaning was done and the residents were in bed. · The VA came upstairs during the night to use the bathroom. P3-P5 provided the following information: · P3 said the VA was not truthful when it came to concerns related to food and P3 was unsure if the VA was able to provide reliable information about other things. The SP told P3 about an incident when the SP confronted the VA about “digging in the garbage” and the VA became upset. This occurred shortly after the VA moved to the facility in September 2025, and was not close to the time the VA made the allegations against the SP. There were no other incidents of concern between the SP and the VA. · P3 said the VA went to bed before the other three residents and s/he never witnessed the VA upstairs after the other three residents went to bed. P3 did not witness any concerning behavior from the SP and had not seen the VA and the SP converse. On November 14, 2025, P3 worked until 7:30 p.m. and was off on November 15-16, 2025. · On November 21, 2025, the CP contacted P5 and notified him/her of the information the VA disclosed. P5 contacted P4 and informed him/her of the allegations. P4 spoke to the SP, and the SP denied the allegations and that s/he ever touched the VA. The SP mentioned that the allegation included “inserting [the SP’s] finger into the [VA].” P4 had not given the SP that information. (Note: At this time the SP had already spoken to law enforcement about the allegation). The VA told the CP the incidents happened with the SP two weekends in a row, November 7-9, 2025, and November 14-16, 2025, however the SP only worked the weekend of November 14-16, 2025. · The SP said all the residents at the facility, including the VA, went to bed at 8 p.m., the VA never stayed up late, and did not need assistance after the VA went to bed. · P4 said the VA’s IAPP and ISSA referred to the VA “potentially not being truthful at times.” The VA had a “complicated history of being caught not telling the truth” and was “capable of relaying factual information.” · P5 said the VA had a history of “issues with boundaries” and not being truthful. The VA previously lived in a facility with staff persons and residents of the opposite gender and had never made sexual allegations against any of them. Prior to telling the CP, the VA did not tell any facility staff persons about the allegations. On November 21, 2026, after the facility learned of the allegations, the police were called, an ambulance transported the VA to the hospital to be examined, and the SP was placed on administrative leave. · There were no previous concerns about the SP and P5 was “surprised” by the allegations. The SP provided the following information: · The SP worked the 3-11 p.m. shift during the week and 8 a.m. to 4 p.m. shift every other weekend. The SP picked up three overnight shifts the weekend of November 14-16, 2025. The SP denied ever touching the VA, having the VA sit on his/her lap, sucking on the VA’s breasts/nipples, or touching the VA’s genitals. · On an overnight shift in November 2025, the SP confronted the VA for trying to take food out of the trash between 1-2 a.m. and the VA ”was not happy about it.” The SP informed P3 about the incident. The SP stated the incident occurred a “couple days” before the VA made the allegations about the SP. (Note: When asked, the VA denied that this incident occurred). · The facility had two staff persons working the morning and afternoon shift and one staff person worked the overnight shift. · The VA did not need assistance with mobility, bathing, toileting, or feeding. The VA had a strict diet and tried to “steal” food. · Typically, medications were administered by staff persons by 7 p.m. Snacks were given and hygiene tasks were completed by 7:45 p.m. and all residents were in bed by 8 p.m. Staff persons checked the upstairs residents’ rooms to make sure bedding was clean and clothes were available for the morning, which took five to six minutes. The VA went to bed at the same time as the other residents. · The SP did not talk to the VA very often and conversations were generally about the VA’s diet. The HP provided the following information: · The VA was examined at the hospital and the HP did swabs for contact DNA. The VA told the HP the SP “sexually touched” the VA on multiple nights and the contact involved the VA’s breasts and genitalia. · The VA told the HP there were two staff persons working at the time of the incident and the other staff person was helping the other residents get ready for bed. The SP carried the VA to the couch in the living room and that was where the incident occurred. · The VA was “very concrete,” “easily distracted,” and was able to give descriptions. The G provided the following information: · The VA lived at a previous facility with staff persons and residents of the opposite gender and had not previously made allegations of this nature. · The VA’s previous provider described the VA as a “storyteller” and stated the VA may not provide accurate information. · One of the VA’s vulnerabilities was if the VA was told something was “okay”, s/he would be easily convinced to do it, even if s/he knew it was not good for him/her. · The G spoke to the VA when the VA was at the hospital and the VA said s/he was “great” and was comfortable returning to the facility. · The VA was very detailed when s/he explained what happened. The G stated the VA could have watched something on the internet or taken the details from past abuse. Facility showed timecards showed the following: · November 14, 2025: the SP started work at 2:56 p.m. and worked overnight. P1 worked until 9:59 p.m. · November 15, 2025: the SP started work at 9:58 p.m. and worked overnight. P1 worked until 10:01 p.m. · November 16, 2025: P1 started work at 10:51 p.m. and worked overnight. The SP worked from 3-11 p.m. Information from medical records showed that on November 21, 2025, the VA had a medical forensic exam. During the exam, the VA told the HP that the SP lifted the VA up and carried the VA to the living room, “sucked on [the VA’s] breasts,” and inserted his/her finger into the VA’s “private parts.” The VA told the HP that P1 was at the facility at the time of the incident but was in another area of the facility getting the other residents ready for bed. The VA stated the experience was “uncomfortable” and the SP repeatedly told the VA to “keep it a secret.” The VA showered, brushed his/her teeth, changed clothing, had a bowel movement, ate food, drank fluid, urinated, and washed his/her hands since the incident. Hair and blood samples were collected and the VA’s breasts and genital area were swabbed for DNA evidence. A law enforcement officer provided information that according to the Minnesota Bureau of Criminal Apprehension’s Forensic Laboratory report there was “No male DNA found” on the samples collected from the VA. The Minnesota Bureau of Criminal Apprehension’s Forensic Laboratory report showed DNA samples from the VA were tested and “items were not suitable for DNA testing.” Therefore, DNA profiling (or further processing) was not possible/performed. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults and on the VA’s plans. Conclusion: The VA consistently said that on November 14-16, 2026, the SP, while working the overnight shift had the VA sit on the SP’s lap, lifted and carried the VA to the living room, sucked on the VA’s breasts and nipples, and touched the VA’s genitals after the other residents went to bed. The VA gave conflicting information on whether the SP was the only staff person working at the time of the incidents or if other staff persons were present at the facility during the incidents. The VA also gave conflicting information whether s/he was downstairs and came up to use the bathroom, s/he came upstairs to get a snack, and/or that the VA was upstairs prior to the incidents and had not yet gone downstairs to bed. P1-P4 each never saw the VA upstairs after 8:30 p.m., unless the VA came upstairs to use the bathroom. P1-P5 each had no prior concerns with the SP. P1 who worked during the evenings on November 14 and 15, 2025, until 10 p.m., never saw the SP and VA alone together and the VA was downstairs in his/her bed when P1 left the facility. P1 worked the overnight shift on November 16, 2025. The SP denied the allegations and stated s/he never touched the VA and that communication between them was limited. Although the VA provided consistent information to P2, the CP, and the HP that the SP sucked on the VA’s breasts and touched the VA’s genitals, given that the VA provided inconsistent information about other information surrounding the incident, that the VA did not always provide accurate information, that DNA samples from the VA’s body swabs were “not suitable for testing,” that staff persons had no concerns with the SP, that P1 stated the VA always went downstairs to bed by 8 p.m. and was downstairs by 8 p.m. on November 14-15, 2025, that P1 never saw the VA and the SP alone in a space together, and that the SP denied the allegations, there was not a preponderance of the evidence whether any sexual contact 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 policies and procedures were adequate and followed. The SP was no longer at the facility. The VA’s plans were revised. Action Taken by Department of Human Services, Office of Inspector General: No further action.
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