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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: 1071715-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Carla Harvieux 651-431-6616 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not wear underwear under his/her clothing when s/he worked with a vulnerable adult (VA) which exposed the SP’s genitals, that the SP viewed sexually explicit material on his/her cell phone while working, that the SP intentionally exposed his/her genitals to the VA in a community bathroom, and that the SP drew a penis on the VA’s arm. Date of Incident(s): Prior to May 13, 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 (b), clause (2); and subdivision 2, paragraph (c); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 May 27, 2026; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, and the SP), the VA, and the VA’s guardian (G). Facility documentation showed that the VA’s diagnoses included a developmental disability. The VA required continuous one to one supervision at the facility and in the community, was vulnerable to sexual exploitation, and might have poor boundaries with others. If the VA wanted to “dominate” a situation. s/he might get into others’ personal space. A rights restriction prohibited the VA from possessing explicit materials and s/he was not permitted to access the internet. The VA had a good memory and was usually able to recall and retain information, but s/he might provide inaccurate information when persons s/he did not know well were present. The VA liked to stay active, wanted to help people that s/he cared about, and enjoyed going to parks. The facility’s Internal Review and interviews with this investigator provided the following: · The VA said that s/he felt the SP acted unprofessionally on shift between January and April of 2026. The SP did not zip his/her pants which exposed his/her genitals and wore pajama pants without underwear and clothing that showed his/her stomach. When the SP bent over, his/her buttocks were exposed. The SP frequently used the restroom at the facility for up to one and a half hours each time, and the VA thought that the SP watched explicit videos in the restroom and in common areas of the facility because the VA heard the videos playing. When the VA walked in on the SP watching explicit videos, the SP quickly hid his/her phone. In addition, the SP covered him/herself with a blanket at the facility and kept his/her hands under the blanket, which triggered the VA. On a date the VA could not recall at a community location in a restroom designed for simultaneous use by multiple persons, the VA and the SP were in the restroom at the same time when the SP exposed his/her genitals to the VA. In late April 2026, the SP drew a penis with an ink pen on the VA’s arm, but the VA did not realize it was a drawing of a penis. The VA was embarrassed by the drawing, ashamed that s/he did not realize that the drawing was a depiction of a penis, and tearful during the interview with this investigator. · The SP said that s/he often wore pajama pants, sweatpants, jeans, and t-shirts when s/he worked at the facility, but s/he always wore underwear when s/he was on shift. The SP was unaware of a time when s/he wore clothing that revealed his/her body or genitals to the VA. On a date s/he could not recall, s/he was with the VA at the store in the community when the SP suddenly needed to use the restroom. The VA required continuous supervision in the community, and s/he was the same gender as the SP, so the VA went into the bathroom with the SP, and they used the restroom at the same time. The SP said that the VA did not see his/her genitals in the bathroom because there were dividers between the toilets and s/he turned his/her body to prevent the VA from seeing his/her genitals when s/he used the bathroom. · The SP acknowledged that s/he drew on the VA’s arm with a pen but said that s/he drew a flower not a penis and thought that P1, a supervisory staff person, saw the drawing. The SP later learned that s/he should not have drawn on the VA’s arm and apologized to him/her. According to the SP, other staff persons at the facility provided inaccurate information about him/her at work and in the community because they disliked him/her. · P1 said s/he did not see the drawing on the VA’s arm and did not know what the SP drew. P1 had no firsthand information regarding the allegations but said that various staff persons voiced their concerns regarding the SP after the SP was no longer employed at the facility. P1 felt that the SP’s behavior was immature, but s/he did not see the SP wearing inappropriate clothing on shift and had no information regarding his/her interaction with the VA in the community bathroom. However, P1 thought that the SP showed the VA a photograph on the SP’s phone of the SP’s significant other wearing a swimsuit, which was upsetting to the VA. P1 talked with the SP regarding the use of cell phones at work, and reminded him/her that staff persons were not to use their phones on shift. · P2 did not have firsthand information regarding the concerns in this report but talked with the VA after concerns were raised. The VA told P2 that the SP’s actions were upsetting and that s/he felt triggered by them. Facility documentations showed that P1, P2, and the SP were trained on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Related Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) states that a person’s rights include the right to be treated with courtesy and respect. Conclusion: Information was consistent that the VA provided similar information over time to staff persons and in an interview with this investigator that the SP wore clothing to the facility on several occasions which showed his/her genitals and/or buttocks, that the VA thought s/he heard the SP watching explicit videos on his/her phone, that the VA saw the SP’s genitals in a community multiuser bathroom, and that the SP drew an image on the VA’s arm. There was conflicting information regarding the drawing; the VA thought it was a depiction of a penis, but the SP said that s/he drew a flower on the VA’s arm. The VA was tearful when s/he discussed the incidents with this investigator. While the VA had a good memory, s/he might provide inaccurate information when persons s/he did not know were present. The SP said that his/her clothing covered his/her body at the facility and that s/he always wore underwear with his/her pants. In the bathroom in the community, the SP was sure that the VA did not see his/her genitals because there were dividers between the toilets and the SP positioned him/herself to block the VA’s view of his/her genitals. However, the SP drew a flower on the VA’s arm with pen but denied that the drawing was of a penis. The SP said that P1 saw the drawing, but P1 stated that s/he did not see it and learned of concerns regarding the SP’s behavior after the SP was no longer employed at the facility. P1 and P2 did not have firsthand information regarding the concerns. P1 thought that the SP’s actions were immature and P2 said that the VA told him/her that s/he felt triggered by the SP’s behavior. The SP drew an image on the VA which was non-therapeutic conduct, behavior that was inconsistent with the standards of a professional caregiver in a DHS licensed facility, and a violation of Minnesota Statutes, section 245D.04. Regarding sexual abuse: Although there was conflicting information whether the VA saw the SP’s genitals when the SP worked with the VA, no information showed that the SP had sexual contact with the VA. Therefore, there was a not a preponderance of the evidence that sexual abuse occurred. It was determined that sexual abuse did not occur (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 abuse and neglect: Although the VA was tearful when s/he discussed the incidents, that the SP might have worn pajama pants on shift at the facility and/or engaged in activities that might have triggered the VA, given that there were no witnesses to the incidents to confirm or dispute the SP’s or the VA’s information, that the SP stated s/he wore underwear and did not expose his/her genitals, that the incident that the SP drew on the VA’s arm was not repeated, and the VA had a history of providing inaccurate information, there was not a preponderance of the evidence whether there SP’s actions caused the VA emotional distress or whether there was a failure to provide the VA with care that was reasonable and necessary to obtain or maintain his/her health and safety. It was not determined whether abuse or neglect occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening; or 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). Action Taken by Facility: The facility completed an Internal Review and determined that policies and procedures were adequate but were not followed. All staff persons who worked with the VA were retrained on reporting incidents and professional boundaries. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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