The state’s unusually swift and vigorous discipline of a northern Minnesota care facility where a vulnerable adult is believed to have been subjected to a fatal beating signals a larger effort by the Minnesota Department of Health to follow through on promises of tighter scrutiny over the senior care industry.

In early November, state health investigators arrived at Chappy’s Golden Shores, a small assisted-living facility south of Grand Rapids, to investigate complaints of maltreatment. They uncovered what appeared to be alarming levels of violence — including physical, sexual and verbal abuse — and repeated coverup efforts by facility administrators.

By Dec. 6 they had suspended the facility’s license — an unusual step that, in effect, caused it to shut down — and had begun working to relocate all 38 residents.

“I’ve never seen the [Health Department] come down this quickly and this forcefully on the side of protecting our vulnerable adults and the elderly,” said Sen. Jim Abeler, R-Anoka, chairman of the Senate Human Services Reform Committee. “There was an urgency here that we haven’t seen in the past.”

The episode reflects a broader shift at the agency, which came under sharp criticism a year ago for insufficient efforts to protect tens of thousands of vulnerable adults in senior care facilities across the state.

In late 2017, a Star Tribune series chronicled long delays in state maltreatment investigations, lost or destroyed files, and poor communication between the agency and abuse victims and their relatives. A scathing report by Legislative Auditor James Nobles followed a few months later.

Pressured to change

Under pressure from families and legislators, new Health Commissioner Jan Malcolm overhauled the agency’s system for responding to and investigating allegations, eliminating a vast backlog of never investigated cases while speeding up the pace of new investigations.

The changes are starting to show substantial results.

Since 2015, the Health Department has more than doubled the number of maltreatment investigations it completes annually, and is conducting them at a much faster pace. In the past, abuse victims and their families would sometimes be forced to wait a year or longer for basic information from the agency. Now, every allegation of maltreatment is examined within two days, and the average time to complete investigations has dropped by nearly half, from 187 days in 2017 to 110 days last year, state data show.

In addition, the agency is “substantiating” a greater portion of maltreatment allegations, which means that more facilities and employees are being held accountable for wrongdoing. The department’s Office of Health Facility Complaints (OHFC) substantiated maltreatment in nearly 30 percent of the cases it investigated last year. While some elder care advocates still consider that too low, the figure is up significantly: The OHFC substantiated only 16 to 19 percent of its investigations between 2012 and 2016.

“The progress is very real,” Malcolm said in an interview. “We feel much more confident today that when serious issues are brought to our attention, that we spot them and are able to get to them more quickly.”

In the past, state investigators had come under criticism for not treating incidents of physical or sexual abuse with urgency, and for relying too heavily on interviews with facility supervisors and staff. The legislative auditor’s report said investigators sometimes failed to interview key witnesses, including the vulnerable residents who were victimized.

By comparison, the state inquiry into Chappy’s Golden Shores cast an unusually wide net. Starting in November, the Health Department launched nearly a dozen separate investigations of the facility and also interviewed members of the community. Investigators talked to therapists, crisis intervention workers, county social workers and physicians who had relationships with residents in the facility and could be seen as trusted sources.

“It indicates a significant shift in thinking” at the agency, said Suzanne Scheller, an elder law attorney from Champlin who reviews hundreds of state maltreatment reports each year. “It shows they are concerned with the thoroughness of their investigations rather than following a predetermined process.”

‘Weren’t messing around’

Marie Skelly, a former caregiver at Chappy’s, said she can still recall the evening in early November when a team of state investigators appeared — unannounced — at the front door.

“They came in like the cops, and it was clear they weren’t messing around,” she said.

Eventually, the state would determine that a 58-year-old man with dementia, Steven G. Nelson, was severely beaten by a caregiver at Chappy’s while another employee held him down and a third watched and did not report it. Nelson later died of apparent brain injuries.

In addition, the agency determined that two staff members had sexual relations with a female resident with quadriplegia who was confined to a wheelchair. Separately, a resident with Parkinson’s disease was hit on the head with a frying pan by a staff member while another threatened to kill his cat. And a man with anxiety suffered a decline in his mental health after he was subjected to a torrent of verbal abuse, the state found.

Staff members at Chappy’s also told investigators they were prohibited from reporting maltreatment by management, and were not allowed to accurately document events, the agency found. Two residents reported having their phones taken away when they attempted to call “911” to report abuse, according to the investigations.

Founded 23 years ago, Chappy’s housed a diverse mix of clients, including older residents with dementia and younger people with disabilities and mental health problems.

The facility’s owner, Tricia Olson, said she is the victim of a “sham investigation” and has appealed the 90-day suspension of Chappy’s license. “We did our job to the fullest and took care of all these people,” she said.

Sen. Scott Dibble, DFL-Minneapolis, said the Chappy’s case underscores the need for stronger protections for residents of senior care facilities. More timely and thorough investigations, while important, won’t suffice to protect seniors from violent crimes, Dibble said. He noted that the Health Department still receives more than 400 reports of maltreatment at health facilities each week.

Dibble plans to introduce broad legislation next week, backed by a coalition of senior advocacy groups, that would require assisted-living facilities to be licensed by the state. It also would clarify state law to give people the right to place cameras in senior homes to monitor care of their loved ones, among other changes.

“What’s going on where 400 times a week something awful is happening to our vulnerable seniors?” Dibble asked. “Clearly a whole lot more needs to be done to change behavior inside these institutions.”