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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: 1098078-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Brittany Dolen 651-431-3676 Suspected Maltreatment Reported: It was reported that the facility did not take appropriate action to protect two vulnerable adults (VA1 and VA2) when on two occasions, VA2 had sexual contact with VA1 that was not consensual. Date of Incident(s): July 20 and 28, 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 17, paragraph (a): 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 August 18, 2026; from documentation at the facility and law enforcement records; and through seven interviews conducted with two supervisory staff persons (P1 and P2), a staff person (P3), VA1’s case manager (CM1), VA2’s case manager (CM2), VA1’s guardian (G1), and VA2’s guardian (G2). Attempts were made while on the site visit and via telephone to contact and interview another staff person (P4), however those attempts were unsuccessful. VA1 and VA2 were interviewed but did not provide information relevant to the investigation. VA1 was diagnosed with bipolar disorder, intermittent explosive disorder, mild intellectual disabilities, unspecified disorder of adult personality, and behavior and attention deficit hyperactivity disorder. VA1 enjoyed cooking, spending time with his/her family, going to church, and listening to music. VA1’s Individual Abuse Prevention Plan said VA1 had a “limited” understanding of sexuality, “lacked” the ability to identify potentially dangerous situations and/or deal with “sexually abusive” or aggressive persons, and often misread signs, signals, and social cues. VA1 did not always understand how to advocate for him/herself due to his/her diagnosis and could “unknowingly” cooperate in abuse from others. VA1 had difficulty expressing his/her needs appropriately and required verbal reminders and/or prompts to complete tasks thoroughly. VA1 was “very observant” and would “absorb” and “mirror” other individual’s memories of significant incidents. VA1’s Support Plan Addendum said VA1 could not be left unsupervised at the facility and did not require awake overnight supervision. Staff persons provided VA1 “visual supervision” in the community. VA2 was diagnosed with unspecified mood disorder, impulse disorder, and mild intellectual disabilities. VA2 enjoyed sports and fishing and spending time with his/her family. VA2’s Individual Abuse Prevention Plan said VA2 had a history of physical aggression towards others and did not recognize unsafe situations. VA2 required assistance with maintaining “safe boundaries” related to physical and verbal aggression towards others and did not require awake overnight staffing. Law enforcement records provided the following information: · On July 20, 2026, P4 called law enforcement to report a “possible” sexual assault. At 8:11 a.m., a law enforcement officer (LEO1) arrived at the facility and spoke with P4, VA1, and VA2. P4 said that VA1 told P4 that VA2 rubbed VA1’s “back and butt” while VA1 and VA2 were in VA1’s bedroom. · VA1 told LEO1 that VA2 touched VA1’s leg and back and “pushed” VA1. LEO1 asked if VA2 touched VA1’s butt and VA1 “nodded” his/her head. · VA2 told LEO1 that VA1 was in VA2’s bedroom and got on VA2’s bed. VA2 “yelled” at VA1 to get off his/her bed and leave his/her bedroom. VA2 denied touching VA1’s butt. · On July 29, 2026, P4 again called law enforcement and at 8:19 a.m., and LEO2 was dispatched to the facility. When LEO2 arrived, P4 told LEO2 that VA1 said that the previous night, at an unknown time, VA2 came into VA1’s bedroom, made “thrusting” motions, and touched VA1’s butt. P4 then told LEO2 that VA1 and VA2 would be separated, and that they were both safe at the facility. · LEO2 then contacted P2 who said P3 worked the overnight shift and was allowed to sleep during the overnight. · LEO2 did not speak with VA1 or VA2 on July 29, 2026, and there was no further action taken. P1 and P2 provided the following information: · On July 20, 2026, VA1 said that VA2 touched him/her so P1 requested the overnight position be changed from asleep to awake and while waiting for the approval, supervision was “ramped up” to ensure safety for VA1 and VA2. P2 said that after the first incident, Staff persons were told that VA1 and VA2 could not be alone together, and staff persons needed to provide “extra” supervision. The LEO also told VA1 and VA2 they could not go into each other’s bedroom and told VA2 that s/he could “get in big trouble” if s/he did so. Awake overnight supervision had not yet been approved when the second incident occurred. · On July 29, 2026, at an unknown time, P4 called P2 and said that VA1 told P4 that VA2 went into VA1’s bedroom in the middle of the night. VA2 was “naked” and tried to “hump” VA1. P2 told P4 to call 9-1-1 and then texted P1 about the incident. P1 told P2 to provide “constant” supervision to VA1 and VA2. P2 then drove to the facility and when s/he arrived, spoke with P4 who said s/he never saw anything sexual between VA1 and VA2. · P1 then spoke with VA1 who said that VA2 came into VA1’s bedroom but VA1 did not want VA2 in his/her bedroom. VA1 did not provide any additional information. P1 talked to VA1 about ways to ensure that VA1 felt safe at the facility. VA1 decided s/he would lock his/her bedroom door, and staff persons would have a key. P1 then spoke with VA2, who “shut down” and did not answer when asked if s/he went into VA1’s bedroom. · After P1 spoke with everyone at the facility, s/he decided that immediately the overnight shift would become an awake overnight shift, and that staff persons would watch the hallway and check on VA1 and VA2 “frequently” and/or have “line of sight” to VA1’s and VA2’s bedrooms. · VA2 did not have a history of sexualized behavior, and neither P1 nor P2 thought VA1 or VA2 were accurate providers of information. VA1 had a history of providing “false” information, and VA2 “elaborated” information. P3 provided the following information: · P3 typically worked the asleep overnight shift at the facility and although staff persons were able to sleep during this shift, P3 was up “most of the night.” On an unknown date, the facility changed the overnight position to be awake because of something that may have happened between VA1 and VA2. · On an unknown date, after the July 29, 2026, incident, VA1 told P3 that VA2 came into VA1’s bedroom unclothed. VA2 used his/her finger to motion to VA1 to come towards VA2 but VA1 said, “No.” VA2 then entered VA1’s bedroom and VA2 put his/her hands in VA1’s pants and “grabbed” VA1. VA1 then provided different details and said the incident happened in VA2’s bedroom and then said it happened in the facility bathroom. At one point, VA1 told P3 that VA1 “lied” a couple of times. · VA2 told P3 that VA1 tried to come into VA2’s bedroom. On multiple occasions during his/her overnight shift, P3 saw VA1 try to go into VA2’s bedroom. P3 redirected VA1 telling VA1 that s/he could not go into VA2’s bedroom and VA1 became “upset.” P3 never saw VA2 try to go into VA1’s bedroom. · All of the bedrooms were in the same hallway so P3 could hear if/when VA1 and/or VA2 opened their bedroom doors. Both VA1 and VA2 required staff persons to be present at the facility but did not require overnight awake supervision. P3 was not aware of any previous incidents between VA1 and VA2. G1 was aware of the allegations and thought VA1 was an accurate provider of information. G2 was aware of the incident on July 20, 2026, but was not aware of the incident on July 29, 2026. G2 did not believe VA2 was an accurate provider of information due to his/her diagnosis. Personnel files showed that P1-P4 were trained on the VA’s plans, and the Reporting Maltreatment of Vulnerable Adults Act. Conclusion: Information was consistent that VA1 said on July 20 and 29, 2026, VA2 came into VA1’s bedroom and touched VA1’s back, leg, and/or buttocks and the second time VA2 was unclothed and tried to “hump” VA1. However, VA1’s details of the incident varied including the location of the incidents and VA2 denied the actions as described by VA1. Although VA1 said that VA2 entered VA1’s bedroom twice and touched VA1, given that VA1 provided varied details about the incidents and there were concerns about VA1’s ability to provide accurate information, that VA2 denied the incidents, that neither VA1 nor VA2 required awake overnight supervision at the time of either incident, and that after each incident the facility took immediate actions including contacting law enforcement and requesting awake overnight staff, there was not a preponderance of the evidence whether there was a failure to supply VA1 and/or VA2 with care or supervision that was reasonable and necessary to maintain their physical or mental health or safety. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed. The asleep overnight shift was changed to an awake overnight shift until VA2 moved out of the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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