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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: 1116924-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy 651-431-3444 Suspected Maltreatment Reported: It was reported that a staff person (SP) had sexual contact with a vulnerable adult (VA). Date of Incident(s): June 6, 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), clauses (1) and (2): Any contact with the vulnerable adult that is not therapeutic conduct and a reasonable person would consider a sexual act or any nonconsensual sexual interaction with the vulnerable adult, including but not limited to: · making, viewing, or sharing sexual images or videos with or of the vulnerable adult; and · using oral, written, gestured, or electronic communication that is sexually harassing, including but not limited to unwelcome sexual advances or requests for sexual favors. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 18, 2026; from documentation at the facility, law enforcement records, and medical records; and through twelve interviews conducted with two facility supervisory staff persons (P1 and P2), a staff person (P3), the SP, a day program staff person (DPS), the VA’s case manager (CM1), the VA’s former case manager (CM2), the VA’s therapist (T), three of the VA’s family members (FM1, FM2, and FM3), and a resident’s (R1’s) family member (FM4). The VA was interviewed by a sexual assault nurse examiner (SANE). The VA enjoyed shopping, attending church, going out to eat, watching television, working on art projects, and spending time with his/her friends and family members. The VA’s diagnoses included mild intellectual disabilities, anxiety, major depressive disorder, and glaucoma. The VA attended a day program every weekday. The VA was not subject to guardianship. The VA’s Individual Abuse Prevention Plan stated that the VA was unable to identify potentially dangerous situations and might not be able to defend him/herself against abuse. The VA had a lack of understanding of sexuality. The VA might report abuse to the right people, but the report may not always be correct or truthful. The T provided the following information: · On June 7, 2026, at approximately 6:30 p.m., the VA called the T and told him/her that the previous night the SP told the VA that s/he had a “crush” on the VA and “loved” the VA. The VA and the SP took off their clothing and “made love” even though the SP “didn’t want to do it.” The VA was currently upset because the SP was “mad” at the VA and did not want to make love with the VA again. The SP also told the VA that s/he was going to quit his/her job. The T asked the VA several times if they had sex and the VA always responded by saying they “made love.” The VA told the T that the SP was mad at him/her and “looked angry.” The T then briefly talked to a staff person, but did not know the staff person’s name. The T attempted to call the facility’s main office but was unable to contact anyone so s/he called 9-1-1 to tell them the VA might be in a threatening situation. A law enforcement officer (LEO) then went to the facility. · The following day, the T again talked to the VA, who told the T that the previous night s/he was taken to the hospital where tests were done. The VA asked the T why the SP made love to the VA and told the VA that s/he loved the VA. [Note: The VA used more explicit terms describing what occurred than s/he had the previous day when s/he talked to the T. These terms were not used in the report to maintain gender neutrality.] The VA was concerned that others were mad at him/her. The hospital’s After Visit Summary and Patient Assault History stated that on June 7, 2026, the VA was seen at the hospital’s emergency room because of a sexual assault the previous day. While at the hospital, the VA was interviewed by a Sexual Assault Nurse Examiner. The VA told the nurse, “[S/he] said [s/he] loves me. [S/he] told me not to tell.” When asked if s/he was in pain, the VA said, “Yes,” but it was “emotional” pain. The VA denied any physical injuries or pain. When asked to talk about details the incident, the VA said, “I can’t say it. [S/he’s] probably mad at me.” When asked about what the VA meant when s/he said they “made love,” the VA said, “I don’t know, what do [wo/men] do this for?” When asked if the SP touched the VA anywhere, the VA said, “No, I think [s/he’s] mad at me.” The VA also said, “I wish it did not happen. Oh, because I learned about this thing, I learned about it on TV.” When asked again where the SP touched the VA, the VA said that the SP’s genitals touched the VA’s genitals and when asked if it hurt, the VA said, “Yes.” The VA said, “Let’s making love [sic], is making love for that?” The VA also said, “I don’t know, it was sick, [s/he’s] sick, and [s/he] said [s/he’s] in love with me.” The VA later said that the SP told the VA, “I’m going to be in jail,” and the SP yelled at the VA and told the VA that s/he will “probably quit.” The LEO’s Report on the Examination of Physical Evidence, stated that none of the swabs done on the VA produced evidence suitable for DNA testing. The report was sent to the county attorney for review of possible charges. P1 – P3 provided the following information: · On June 7, 2026, at approximately 7:30 p.m. the SP called P1 and said that the VA called the T and said that the previous day, the SP sexually assaulted him/her. The T then talked to the SP and told him/her that the LEO was on his/her way to the facility. The SP told P1 that earlier that day, R1 called the SP asking him/her to look for his/her iPad in his/her bedroom. While doing so, the VA followed the SP and approached the SP “sexually.” The SP told the VA that s/he was a staff person and they “don’t do this.” The VA then asked the SP if s/he was mad at the VA. The SP then took the VA and another resident (R2) on a community outing in an effort to redirect the VA. P1 stated that R2 was unable to provide information about events. After the SP talked to P1, P1 talked to the VA, who told P1 that s/he and the SP were in love and they had sex in the VA’s bedroom that day and the previous day. When P1 asked the VA what “having sex” meant to the VA, the VA told him/her it was “kissing.” · P3 stated that at approximately 7:30 p.m., the SP called P3 and told him/her that the VA “wouldn’t leave [the SP] alone and asked to make love.” The SP also told P3 that the LEO was called and when the LEO arrived to the facility, they ended the call. The VA went outside to talk to the LEO, who then took the VA to the hospital for an examination. P1 asked another staff person (P4) to finish the SP’s work shift, so the SP could leave the facility. · P2 stated that an on-call supervisor (P5) called P2 to tell him/her about the incident and that the VA was taken to the hospital for an examination. P2 called FM2, who met the VA at the hospital, and asked him/her to update P2 with what happened. That night, the VA returned to the facility. The following morning, P2 went to the facility and briefly talked to the VA about what happened. The VA told P2 that the SP “was a little mean” to the VA because the VA told the SP that s/he loved the SP, but the SP told the VA that s/he “liked all of you” and did not say that s/he loved the VA. The SP also told the VA that s/he had work to do in the staff office and asked the VA to leave, which the VA believed was “mean.” The VA also told P2 that the SP told the VA that s/he had a “crush” on the VA and wanted to “make love” to the VA. The VA told P2 that the incident happened in his/her bedroom, but later told P2 that it happened in R1’s bedroom. At some point, the VA told the SP that s/he was going to go to jail. The VA told P2 that during the incident, R2 was in the living room. · When P2 talked to the SP about the incident, the SP told P2 that the VA repeatedly wanted the SP to say s/he loved the VA, but the SP only said that s/he liked all of the residents. After dinner, the SP was on the phone with FM4, who asked the SP to check R1’s bedroom for his/her iPad. The VA followed the SP to the R’s bedroom. The SP told P2 that s/he was in the bedroom for approximately two minutes and did not find the iPad, so they went back upstairs. A short time later, the VA brought his/her phone to the SP because the T wanted to tell the SP that s/he called 9-1-1 and the LEO was on his/her way to the facility. · P1 stated that for a few days after the incident, the VA brought up the incident and asked, “Why did [s/he] do this to me?” and “Is [s/he] mad at me?” At one point, the VA said that s/he “blew it” with the SP. The VA sometimes repeated things if s/he initially got attention for saying it. P2 stated that the VA was not always an accurate reporter of events. · P1 stated that prior to the incident, s/he had no concerns about the SP’s interactions with the VA or other residents and all of the residents liked the SP. P2 stated that after the incident, only staff persons of the same gender as the VA would work at the facility. The SP provided the following information: · On the weekend of the incident (June 6, 2026), at one point the SP went downstairs to do laundry and the VA followed him/her and asked the SP if s/he “loved” the VA. The SP told the VA s/he “loved everybody” and redirected the VA upstairs. The VA asked the SP again if s/he liked the VA. The SP told the VA that s/he liked everybody. The VA was not happy with the SP’s response, so the SP redirected the VA and then took the residents, including the VA, for a van ride stopping for lunch before returning to the facility. Then “everything was fine” until later in the day when the SP was working in the staff office. The VA entered the office “really agitated,” so the SP tried calling a supervisory staff person who could usually talk to the VA and calm him/her, but the supervisor did not answer the phone. · The SP made dinner and then FM4 called and asked the SP to look for R1’s iPad. When the SP went downstairs to look for the iPad in R1’s bedroom, the VA again followed the SP. The VA told the SP that s/he loved him/her and the SP told the VA to “stop it” because s/he did not want to have that conversation with the VA. The VA “insisted” that the SP tell the VA s/he loved the VA, but the SP became angry and “raised [his/her] voice” and told the VA that s/he was “going to tell [P1].” The SP did not recall exactly what else s/he said to the VA. The SP believed that at that point, the VA got mad at the SP because the SP raised his/her voice. The SP redirected the VA by the shoulder away from the bedroom door and the VA then took the house phone and went to his/her bedroom and the SP went back upstairs. The SP called P3 and while talking to P3, the VA came and gave the house phone to the SP and told the SP that the T wanted to talk to him/her. The SP took the phone to talk to the T who told the SP that the LEO was on their way to the facility. The LEO then arrived at the facility and took the VA to the hospital. · The SP stated that “every time” s/he left the facility at the end of his/her work shift, s/he told the residents that s/he loved them and they should “stay blessed.” The SP never told the VA individually that s/he loved him/her. The SP never hugged any residents, including the VA. The SP stated that s/he never kissed the VA, touched the VA in a sexual manner, or had sexual contact with the VA. On one occasion, when the SP and another staff person took the VA to visit his/her family member, the VA talked about his/her past boy/girlfriends, but the VA never talked about sex. The DPS stated that since the incident, the VA frequently talked to the DPS about how s/he and the SP “made love.” The VA talked to the DPS “pretty much every day” about how s/he did not understand why the SP “did that to me” or why it hurt. The VA would point to his/her genital and stomach areas and say that it “hurt.” CM1 stated that the VA had a history of “being fixated” on staff persons of the opposite gender and sometimes became “obsessed” when s/he believed that another person was “mad” at him/her or did not react the way s/he wanted them to. Several years prior to the incident, the VA provided inaccurate information regarding an incident with someone at his/her residential program. CM1 believed the facility staff persons currently “had a good handle” on how to work with the VA’s attention-seeking behaviors. CM2 stated that from 2017 to 2021, s/he worked with the VA. The VA tended to “try to tell you what you want to hear” or to give what s/he thought was the “right” answer to questions. The VA tended to engage in attention-seeking behavior and sometimes fixated on certain individuals. FM1 stated that the VA did not talk to him/her about the incident and FM1 did not ask the VA questions because s/he did not want to “muddle” the investigation into the incident. FM1 was not aware of any previous occasions when the VA was an inaccurate reporter of events. FM2 stated that s/he and FM3 were with the VA when s/he was at the hospital. At that time, the VA told FM2 that the SP “took [the VA] downstairs and had sex with [the VA]” and “it hurt.” FM2 did not ask the VA questions, but let the VA tell him/her whatever s/he wanted. FM2 believed the VA was an accurate reporter of events. After the incident, the VA repeated asked FM2, “Why did it happen?” FM3 stated that while s/he and FM2 were at the hospital, the VA told him/her that the SP took the VA downstairs and touched the VA’s genital area. The VA initially said that s/he and the SP “made love” and then asked if that was sex. FM3 believed that at the time of the incident, only one other resident was at the facility with the VA and the SP. Prior to the incident, FM3 had no concerns about the care the VA received at the facility. After the incident, the VA was more “emotional” and frequently asked why the SP “did this.” FM4 stated on one occasion s/he called the facility and asked a staff person to look for R1’s iPad. FM4 did not recall hearing anyone yelling during the phone call. The facility’s Staff Schedule and Time Entries stated that on June 6, 2026, from 8 a.m. to 10 p.m., the SP worked at the facility. On July 7, 2026, from 10 a.m. to 9 p.m., the SP worked at the facility. No other staff persons were scheduled to work with the SP during those times. Facility documentation showed that the SP, P1, P2, and P3 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 incident. Conclusion: On June 7, 2026, the VA called the T and said that the previous day, the SP and the VA had sexual contact and that the SP told the VA that s/he loved the VA. The LEO went to the facility and took the VA to the hospital, where s/he was examined and given a SANE examination. However, none of the swabs done on the VA produced evidence suitable for DNA testing. The VA provided consistent information to multiple people that s/he “made love” with the SP but then provided conflicting information about the incident to P2 including whether the SP told the VA that s/he loved the VA, how many times it occurred, where the incident/s occurred, and if anyone was present. The SP stated that on the day of the incident, the VA insisted several times that the SP tell the VA that s/he loved the VA and became upset when the SP refused to do so. The SP denied having any sexual contact with the VA. Although the VA provided mostly consistent information that the SP and the VA had sexual contact, given that the VA also provided conflicting information to P2, that the tests done were not able to produced evidence suitable for DNA testing, that the SP denied touching the VA or having sexual contact with the VA, that no additional information was provided to support or refute either the VA’s and/or the SP’s accounts, and that the VA had a history of “fixating” on staff persons of the opposite gender, there was not a preponderance of the evidence whether the SP had sexual contact with the VA. It was not determined whether sexual abuse occurred (any contact with the vulnerable adult that is not therapeutic conduct and a reasonable person would consider a sexual act or any nonconsensual sexual interaction with the vulnerable adult, including but not limited to: making, viewing, or sharing sexual images or videos with or of the vulnerable adult; and/or using oral, written, gestured, or electronic communication that is sexually harassing, including but not limited to unwelcome sexual advances or requests for sexual favors). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. After the incident, the facility ensured that all of the staff persons at the facility were the same gender as the VA. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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