Andrew Residence: Sexual Abuse Unreported for Six Days - MN
Nobody interviewed her. Nobody documented who was responsible. Nobody filed the required report with the state. The resident, identified in inspection records only as R1, waited from November 7 to November 13, 2025, while the facility gathered what its program director later described as "more information" before making the call to state authorities.
Federal inspectors classified the lapse as immediate jeopardy to resident health and safety. The facility is disputing that finding.
The incident involved a second resident, identified as R2, who had a documented history of multiple incidents with other residents before the November 7 event. That history was known to staff. What the inspection record makes clear is that between the time the abuse involving R1 occurred and the time anyone at Andrew Residence contacted the state, six days passed without a single staff member sitting down with R1 to ask her what had happened or who had done it.
The program director, identified in the report as PD-A, acknowledged this directly during an interview with inspectors. She confirmed that after the incident, the facility waited until it had gathered more information before filing the state report on November 13. She acknowledged she didn't think any staff had investigated or asked R1 what happened or who was involved during that entire window.
The facility's own Vulnerable Adult Reporting Policy, dated September 28, 2022, required something very different. Under that policy, any staff member with knowledge of maltreatment, or with reasonable cause to believe a resident had been maltreated, was required to immediately make a verbal report to a supervisor and complete an incident report. From there, the person in charge was required to inform the administrator. Allegations of abuse were to be reported to the state agency immediately, and no later than two hours after the allegation was made or after forming the suspicion.
Two hours. The facility took six days.
The policy also defined what constituted abuse. Sexual abuse, it specified, is willful, meaning the individual acted deliberately, and includes any non-consensual contact of any type with a resident. There was no ambiguity in the definition that would have required additional information before reporting.
The facility's own written policy required a two-step process: an initial report to the state, followed by a full investigative report within five working days of the incident. The initial report alone, the one that was supposed to go out within two hours, didn't go out for nearly a week.
R2, the resident identified as the aggressor in the incident, had been the subject of staff concern before November 7. By the time a mental health worker identified in the report as MHW-A spoke with inspectors on November 20, hourly checks on R2 were underway, a response to what the inspection record describes as multiple incidents with other residents. MHW-A showed inspectors the signature sheets documenting those checks. There was one missed check, on November 19 at 3:00 p.m.
The hourly monitoring was a protective measure put in place after the fact. It was not in place, or not documented as in place, during the six days when R1 had gone uninterviewed and the state had not been notified.
What the record doesn't say is what R1 experienced during those six days. Whether she asked staff what was being done. Whether she knew a report had been filed. Whether anyone told her anything at all. The inspection report is silent on that. What it does say is that the immediate jeopardy designation, the most serious classification federal inspectors can apply, began on November 7, the date of the incident, and was not removed until November 21, two weeks later.
To get the immediate jeopardy lifted, the facility had to demonstrate it had taken a specific set of corrective actions. Those actions, verified by inspectors on November 21, included reviewing and revising its policies and procedures on reporting and investigating abuse allegations, then educating all staff and leadership on those revised policies with competency verification before the next shift each person worked. The facility also had to interview all residents R2 had access to, including residents on other floors of the building, to assess whether the November 7 incident was an isolated event or part of a broader pattern.
That last requirement carries its own weight. Inspectors weren't satisfied with interviewing residents on a single floor. They required the facility to canvas other floors as well, a scope that suggests R2's movements through the building were not restricted in a way that would have limited contact with other residents.
The facility also had to identify a care plan intervention specifically addressing medication non-compliance, framed in the inspection record as a safeguard related to what the report calls "sexual defiance/deviation." That language points to a documented behavioral concern tied to R2 that predated November 7, one that the facility had a responsibility to manage through care planning, and one that the inspection record suggests was not adequately addressed before the incident occurred.
Finally, the facility was required to identify a plan to assess and monitor female residents with impaired cognition for possible abuse. That requirement is pointed. It identifies a specific population, women with cognitive impairment, as the group the facility now recognized needed targeted protection. It raises the question of how that population was being monitored before November 7, and whether the absence of adequate monitoring contributed to what happened to R1.
Andrew Residence is disputing the immediate jeopardy citation. The inspection was a complaint inspection, meaning it was triggered by a report filed with regulators rather than a routine survey. The complaint that prompted the inspection was filed, based on the timeline in the record, sometime around or after November 7.
The facility's dispute of the citation means the findings have not been finalized as of the inspection record's date. What is not in dispute, because PD-A confirmed it herself, is that six days passed before the state was notified, and that no staff member interviewed R1 during that time.
The immediate jeopardy was removed on November 21 after inspectors verified the corrective actions were in place. R1 had been waiting since November 7.
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 19, 2026 · Our methodology
Andrew Residence in MINNEAPOLIS, MN was cited for abuse-related violations during a health inspection on November 25, 2025.
Nobody documented who was responsible.
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.