Andrew Residence: Abuse Reporting Failures - MN
The facility's own director of clinical services later acknowledged that staff should have asked the resident more questions sooner. The facility is disputing the citation.
The inspection, completed November 25, 2025, was triggered by a complaint. What inspectors found was a timeline that started on November 7 and didn't reach state authorities until November 13, a gap that the facility's own internal policy says should never exceed two hours.
The resident, identified in inspection records only as R1, was described by the director of clinical services as "not always a strong self-advocate." That detail matters, because it helps explain what happened next, and what didn't.
According to the inspection report, a social worker at the facility had knowledge of the incident as early as November 7, 2025. R1 spoke to the program manager about what happened on November 12. She didn't fully disclose the details until November 13, the same day the facility finally made its report to the state agency.
The director of clinical services, identified in the report as DCS-A, was interviewed on November 20 at 3:57 p.m. She said the facility held off on reporting because it didn't yet have the full details. She also acknowledged something more direct: staff should have asked R1 about the incident sooner, given that the social worker already knew about it on November 7.
"Potentially R1 could have disclosed the details sooner if she had been asked about it sooner," the DCS-A said, according to the inspection report.
That is a significant admission. A resident who was not a strong self-advocate, who had experienced a sexual incident, sat in that facility for nearly a week while the staff member who knew about it did not press for details and did not report it. The facility's own director of clinical services said, in so many words, that an earlier conversation might have changed that.
The DCS-A also said the facility did not have to ask R1 again after R1 declined to provide details on November 12. But she added that staff did ask again, and described that as "good on their part." The report does not explain why asking a second time was optional under the facility's reasoning, while asking a first time, between November 7 and November 12, apparently was not considered necessary.
The facility's Vulnerable Adult Reporting Policy, dated September 28, 2022, is unambiguous on the timeline. Allegations of abuse must be reported immediately, and no later than two hours after the allegation is made or after a staff member forms a reasonable suspicion. Any staff member with knowledge of maltreatment, or reasonable cause to believe maltreatment occurred, is required to make a verbal report to a supervisor immediately and complete an incident report. The person in charge is then required to inform the administrator.
The social worker had knowledge on November 7. The report went to the state on November 13. That is not a matter of interpretation.
The inspection report also documents a separate incident involving two other residents, identified as R2 and R4. Staff observed the two residents kissing. When inspectors asked the DCS-A about it, she said, "R4 and R2 just kissed and staff intervened immediately. That was not reportable."
The facility's own policy defines sexual abuse as any non-consensual contact of any type with a resident, and specifies that abuse is willful, meaning the individual acted deliberately. The policy does not carve out exceptions based on the nature of the contact or its apparent severity. Whether the kiss between R2 and R4 was consensual, and how that determination was made, is not addressed in the inspection report. What is documented is that the DCS-A characterized it as not reportable and that staff intervened.
The citation was issued under F0609, which covers the obligation to report and investigate allegations of abuse, neglect, and mistreatment. Inspectors assessed the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The facility is contesting the citation.
That the facility is disputing this finding is worth sitting with. The DCS-A, in her own interview, said staff should have asked R1 about the incident sooner. She said R1 might have disclosed details earlier if she had been asked. She said the facility waited to report because it lacked full details, a rationale the facility's own two-hour reporting requirement does not accommodate. The policy does not require full details before a report is made. It requires a report when a staff member has knowledge or reasonable cause to believe maltreatment occurred.
The social worker had that on November 7.
What the inspection report does not say is what happened to R1 during those six days. It does not say whether she was kept safe from whoever she eventually described. It does not say whether the delay caused her additional harm, or whether the knowledge sitting with the social worker, unreported and unpursued, left her more exposed. The report notes the level of harm as minimal or potential. That assessment reflects the regulatory framework, not necessarily R1's experience of the week that passed before anyone called the state.
Andrew Residence is located at 1215 South 9th Street in Minneapolis. The inspection was completed November 25, 2025.
R1 was described as someone who was not always a strong self-advocate. She eventually told the program manager what happened. She eventually gave the full details. She did what she could. The system built around her, the social worker who knew, the policy that required a two-hour report, the follow-up questions that could have been asked five days earlier, did not move at the same pace she needed it to.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Andrew Residence from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Andrew Residence in MINNEAPOLIS, MN was cited for abuse-related violations during a health inspection on November 25, 2025.
The facility's own director of clinical services later acknowledged that staff should have asked the resident more questions sooner.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.