Andrew Residence: Sexual Abuse Ignored for Six Days - MN
The incident is documented in a federal inspection report completed November 25, 2025, following a complaint filed against the facility at 1215 South 9th Street. The nursing home is disputing the citation.
The female resident, identified in inspection records only as R3, told inspectors she had been afraid. She said the male resident, R2, had asked her personal questions, asked if she wanted to touch or perform oral sex on his penis, and that she told him no. She said he put his penis away but stayed in the room, sat on her bed, and kept making her feel uncomfortable. She thought he still wanted something from her.
R2 told a different story about what he believed was happening, and it is documented in the same report.
During an interview on November 20, 2025, R2 told inspectors he had been having sexual encounters with R3's roommate. After the roommate left, he was alone with R3. He asked to sit on R3's bed. He asked R3 if she had ever had sex with someone, and whether she thought about having sex. He offered to show her his penis. He said she said no, but he still thought maybe she wanted to see it, so he took his penis partially out of his pants, and R3 looked. He then asked if she wanted to see the rest. Since she didn't say no, he took his penis fully out of his pants.
R2 told inspectors he thought R3 looked confused and uncomfortable. He acknowledged it was his duty to ask if she was uncomfortable. He acknowledged he hadn't asked. He put his penis back in his pants and left the room.
The facility's own policy, dated September 28, 2022, defines sexual abuse as non-consensual contact of any type, and specifies that abuse is willful, meaning the individual acted deliberately. The policy requires any staff member with knowledge of resident-to-resident abuse to immediately make a verbal report to a supervisor and complete an incident report. It requires the person in charge to inform the administrator. It requires the facility to report allegations to the state agency immediately, and no later than two hours after the allegation is made.
None of that happened on the day the report came in.
A family member, identified in the report as FM-A, told a social worker about the incident on November 7, 2025. The social worker, identified as SW-A, passed that information to the Program Director, identified as PD-A. And then, for six days, nothing moved. No one followed up with R3. No one asked her what happened or who was involved. No one interviewed R2. No interventions were put in place to protect R3 or any other resident.
The state agency was not notified until November 13, 2025, six days after the facility first received the report.
When inspectors interviewed the Program Director on November 20, 2025, at 1:34 in the afternoon, she confirmed the timeline. She said she became aware of the incident on November 13, when the social worker informed her about the family member's report from November 7. She acknowledged that no one had followed up. She acknowledged the incident had not been relayed to other staff. She acknowledged the investigation should have started sooner.
Then she said she was not sure a full investigation was needed.
She told inspectors that what the facility needed was more details. She said that if the follow-up had happened on November 7, interventions could have been implemented to protect R3 and other residents. She acknowledged that from November 7 to November 13, no staff member had investigated, and no staff member had asked R3 what happened or who was involved.
The facility's own policy requires an immediate verbal report to a supervisor, an incident report, notification to the administrator, and a report to the state agency within two hours. It also requires the Director of Clinical Services to investigate after an internal report is made, and a full investigative report to be submitted to the state within five working days of the incident.
The state report was filed on November 13. That was six days after the family member's call. It was not within two hours.
What R3 experienced in the days between November 7 and November 13, while the facility decided whether a full investigation was needed, is not described in the inspection report. What is described is that she had already told someone she was afraid of R2, that she believed he still wanted something from her even after he put his penis away, and that he had stayed in her room and sat on her bed after she said no.
The inspection report notes that the nursing home is disputing the citation. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting few residents.
R3 is not named. Her age, her diagnosis, her cognitive status, none of it appears in what inspectors documented publicly. What does appear is her account: that she saw something she did not want to see, that she said no before she saw it, and that the man who showed it to her stayed in her room afterward and made her feel like he still wanted something.
And that for six days, no one at the facility where she lives asked her about any of it.
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 nursing home is disputing the citation.
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.