Police did not arrest the assailant, even though he lived at Cedar Cottage and had been identified by an eyewitness. Local prosecutors declined to pursue charges or even interview Grayce Braaten. Several days passed before the home moved Grayce farther from her assailant.

And as of early November — more than three years since the assault — the Minnesota Department of Health has not finished its investigation.

That excruciating wait for justice is common in such cases across Minnesota.

Last year, 85 percent of Health Department investigations exceeded the state's own two-month deadline for looking into senior home maltreatment complaints, according to state records.

The average investigation takes three to five months. Some have lasted more than a year.

Long delays leave many families in limbo, making it impossible for them to move on with their lives and eroding their faith in the state's ability to protect the elderly. The delays also undermine criminal investigations and prosecutions, police and prosecutors say. Key evidence is lost. Witnesses move on.

"A delay of a week, or even a day, can be fatal when it comes to prosecuting elder abuse cases," said Tara Patet, senior prosecutor in the St. Paul city attorney's office. "Memories fade. Pictures of the crime scene aren't taken. Victims stop talking. All those things cause an investigation to go south with the passage of time."

Even representatives of the senior care industry say they're frustrated, as prolonged investigations distract their employees and leave them without clear guidance on how to improve the safety of their facilities.

"No one likes these long delays," said Doug Beardsley, a vice president at Care Providers of Minnesota, a trade association. "Providers are in limbo. Staff aren't certain that a bad thing really happened. And there are missed opportunities to learn and minimize future incidents."

In addition, the delays put Minnesota in violation of federal regulations governing care for the elderly. In 10 of the past 12 years, federal auditors have found that the state Department of Health, which regulates nursing homes and other senior facilities in Minnesota, failed to meet mandatory federal deadlines for responding to abuse and neglect complaints.

States are required, for example, to conduct on-site investigations within two working days after receiving complaints of nursing home violations that could lead to serious injuries or deaths. Year after year, however, the state Department of Health violates this mandate — sometimes taking up to two months to respond to allegations of severe maltreatment, according to audits by the federal Centers for Medicare and Medicaid Services.

Even in emergency cases, where multiple residents are at risk of serious injury or death, the department is sometimes weeks or months too late, according to federal records. At least eight times since 2005, the department has submitted written "action plans" to federal regulators to correct the problem. But the long delays persist.

Department officials say they are taking steps to address these problems — streamlining the way they review complaints and pursue investigations.

"We don't like the position that we're in right now," said Gil Acevedo, assistant commissioner in the Department of Health. "A lot of times, family members are left not knowing what truly happened and the wait just becomes unbearable. They deserve better."

Related story

Clayton Braaten says moving his wife to an assisted-living facility was "by far the toughest decision of my life."

Over six decades of marriage, the couple had become inseparable. They went curling and golfing together, took camping trips to the Badlands of South Dakota and made batches of "hooch," or homemade liquor, for family gatherings.

Braaten did not consider himself a religious man, but he converted to Catholicism to please Grayce and her parents, descendants of German immigrants who had settled in Devils Lake, N.D.

"Grayce meant absolutely everything to me," he said.

Gradually, however, he noticed that his wife was showing signs of dementia. A one-time bookkeeper and a talented seamstress, who could piece together coats and blankets from scraps of old clothes, she could no longer remember how to use a needle and thread. When her doctor asked her what year it was, Grayce Braaten looked bewildered. She frequently woke up at night, groaning in pain after forgetting to take her arthritis medication.

"At first we thought it was just her German stubbornness," Braaten said. "Then we realized that she was really suffering."

In 2013, Grayce suffered a severe stroke while hospitalized for a bladder infection. Suddenly, she was unable to walk, eat or bathe on her own. Clayton began providing round-the-clock care, but the burden soon became impossible for a man who was about to turn 80.

"She was such a strong, strong woman," he said. "And it was really difficult to see her go downhill."

The family scoured the area for senior homes before settling on Cedar Cottage, a 15-bed assisted-living facility nestled in a quiet neighborhood near Lake Bemidji. For the first time in 62 years, the couple slept apart.

raaten visited Grayce twice each day, at lunch and dinner, often bringing her the same homemade chicken dumplings they had cooked together as a young couple. Twice each month, Clayton would push her wheelchair to a nursing home across the street, where they would pray the rosary with a visiting priest.

Then, in the summer of 2014, Clayton Braaten received an urgent call from Cedar Cottage.

"Come right away," the manager said.

At first, Braaten thought Grayce had suffered another stroke. But when he arrived, he learned that an 89-year-old male resident had fondled his wife as she lay in her bed. A nurse's aide had seen the man by her bedside with his hands placed on her hip and thigh, according to court records.

Braaten asked whether anyone had called the police. An employee said no — the staff didn't consider the man a threat, Braaten recalled them saying. That's when he discovered that his wife's assailant was still wandering the facility much as he had before the assault.

Rattled and fearful that the man might return to Grayce's room, family members took turns guarding her door at night.

"My mother was completely helpless," said her daughter, Michelle Braaten, an occupational therapist who lives in Bemidji. "She was capable of recognizing exactly what was happening to her, but she did not have the thought process that would have enabled her to initiate action or to scream out for help."

In the days that followed, Grayce told her family that the man had removed her pajamas and fondled her breasts on at least four other occasions. Each time, she said, she told him to leave her room, but her severe dementia had prevented her from crying out for help. The man had also made suggestive comments about her breasts, saying they "reminded him of a young teenager," according to an affidavit signed by Grayce for a lawsuit brought by the family.

It was not the first time the man had behaved inappropriately toward women in the facility, according to Cedar Cottage employees who testified in the family's lawsuit. Previously, they said, he had wandered into the room of another female resident and asked her to kiss him. On another occasion, a female resident was napping when staff found the man stroking her arm. Eventually, he was warned not to enter female residents' rooms, but the facility never took steps to restrict his movements, according to court testimony by the staff.

Cedar Cottage waited several days after the assault to move Grayce Braaten to a room farther away from her assailant, and to begin checking their rooms more often. The staff also installed a door alarm on his room, but the man soon tore the alarm off the wall and threw it to the floor, according to staff testimony.

Officials at Cedar Cottage said they cannot discuss the incident because of a legal settlement with the Braaten family. The Braatens, too, are limited in what they can discuss. The Star Tribune learned independently through public records about their case and where the incident occurred.

s the weeks went by, the Braatens remained determined to hold someone accountable. Frustrated with local police, they turned to the state Health Department, which had opened an investigation days after the assault. The agency has authority to order corrective steps at state-licensed care homes, and to even suspend or revoke a home's license.

But, they say, the Health Department refused to disclose any details while its investigation was underway — a state law makes such inquiries confidential. As a result, the Braatens couldn't find out what investigators had discovered or see any corrective action the agency had ordered at Cedar Cottage.

The family began to feel that no one in government was taking their case seriously.

Local police had questioned Grayce, but conducted the interview in the dining room at Cedar Cottage while other residents came and went. Clayton said his wife would have provided more details about the deeply embarrassing incident had she been interviewed in private.

They said an official in the county attorney's office told them that criminal charges were unlikely to stand up in court because Grayce suffered from dementia and would make a "poor witness." At no point, however, did anyone with the county attorney's office interview Grayce, Clayton said.

Michelle Braaten said it's "completely ridiculous" to think that her mother would have made a poor witness. "She remembered everything that happened that day — down to the coldness of the man's hands and the clothes he wore."

"The wheels of the criminal justice system didn't fail my mother," she added. "They were never even set in motion."

Former Cass County Attorney Christopher Strandlie, now a district judge in Brainerd, said his office decided against bringing charges due to a lack of physical evidence. The alleged assailant told police he had reached under Grayce's blanket to "keep his hands warm," and the one eyewitness never actually saw him touch Grayce's genital area.

Strandlie added that his office generally does not interview abuse victims, "as a matter of efficiency," but instead relies on police interviews, which it reviewed in Braaten's case.

"She was certainly touched inappropriately. She was a victim," Strandlie said. "But we didn't feel that the contact rose to a level where we could ethically bring charges."

The assailant's age also weighed on the county's decision. "What do you do with an 89-year-old guy?" Strandlie said. "We ran into that."

Out of options, Clayton Braaten went to court and sought a restraining order against the assailant.

"Because the facility is insecure and [the man's] behavior unpredictable, I am in fear for my safety," Grayce Braaten said in a sworn statement with the request. A judge granted the order, preventing the man from being within 1,000 feet of his victim.

The order did not provide Grayce Braaten with much comfort. In her final days, she would sometimes look out the window and, with panic in her voice, ask, "When is he gone? When is he gone?"

Each night, before Clayton went home after visiting, she would insist that he check the windows and make sure they were tightly closed.

In May 2016, two years after the assault, Grayce Braaten died at age 81 of complications related to pneumonia.

A few weeks ago the Braaten family checked on the status of the Health Department's investigation.

They were told it was still open.

Clayton said he still struggles with guilt over placing Grayce in the home. He's trying to persuade authorities to change their approach to investigating abuse cases, particularly those involving seniors with dementia.

His priest suggested that he write letters to everyone involved in her case — local police, prosecutors, City Council members and the Department of Health — explaining how justice broke down and why his wife deserved better.

Braaten started writing the first letter in June.

He is still writing.

Chris.Serres@startribune.com 612-673-4308David.Joles@startribune.com 612-673-7904