In 2007, an unidentified man living at Hillcrest Senior Living in Red Lake Falls, Minn., fell out of bed and became wedged between his bed and the room's heat register.
By the time staff discovered him, he had sustained second-degree burns stretching from his right hip to his ankle.
The case was one of 22 confirmed instances of neglect, abuse or financial exploitation reported to the Minnesota Department of Health's Health Facility Complaint Office between 2005 and 2014 in Kittson, Marshall, Pennington, Polk, Red Lake and Roseau counties.
An investigation by the office concluded the resident's bed should have been at least 24 inches away from the heater.
"Due to a failure of the facility to provide for the safety of residents related to heat registers, it was determined that a serious threat to resident health and safety existed," special investigator Marilyn Norling wrote in a report about the incident.
Staff at Hillcrest Senior Living did not return calls for comment.
In other confirmed cases of maltreatment published in state reports, staff stole medication and money from patients, caused physical harm through hitting and did not initiate CPR when patient records said it should be performed, which resulted in the death of at least two patients.
At a REM Northstar facility in Crookston, a client received first- and second-degree burns on her left leg when she was left unsupervised and spilled hot coffee on herself in October 2010.
Executive Director Connie Menne said the company has zero tolerance for neglect and abuse and has a number of training protocols to prevent maltreatment.
"On at least an annual basis, each individual's supervision levels are reviewed by the care team," she said. "These discussions are outlined in a risk plan, and all employees are trained on these plans."
At least 40 hours of training and orientation are required of new employees, Menne said.
Keeping updated standard practices, such as patient care procedures, is advocated by organizations such as Care Providers of Minnesota - a nonprofit membership organization for care facilities such as nursing homes.
"If there are problems out there, we want to see them resolved," said Doug Beardsley, vice president of member services for Care Providers. "Standards of practice keep changing and require higher and higher expectations, which is appropriate. We don't want people in pain."
More than 2,600 health facilities are licensed by the Minnesota Health Department and fall under the jurisdiction of its Health Facility Complaint Office.
Those facilities include nursing homes, hospitals, boarding care homes, supervised-living facilities, home care providers, hospice programs and residences, assisted-living providers and freestanding outpatient surgical facilities.
Alleged incidents of maltreatment at all Minnesota facilities generated 1,345 complaints statewide in 2013, according to the most recent annual "Allegations of Maltreatment in Minnesota Health Care Facilities" report submitted to the Minnesota State Legislature.
Complaints are not as prevalent in northwestern Minnesota as they are in more urban areas, but dozens were filed between 2005 and 2014.
Total, 58 complaints were received during that timeframe for facilities in the six aforementioned northwest counties. While 22 allegations were substantiated, 36 were not confirmed or the investigation was inconclusive.
Complaints: List of northwest Minnesota county complaints
Allegations of maltreatment - accidents are not reportable - can be submitted to the complaint office by residents, by someone on their behalf or by "provider-initiated" reports, which means the care provider brings allegations forward for investigation.
REM received six complaints during that 10-year time period, though only one involving the client burned by coffee was confirmed by investigators.
Even unconfirmed allegations prompt action, according to Menne.
"In these situations, we do review the incident and - consistent with our high standard for quality - we routinely re-train our employees and revise our protocols as warranted," she said.
Complaints constituted only 7 percent of maltreatment incidents reported to the state.
Incidents coming out of facility self-reports represent an overwhelming majority of those filed with the Health Facility Complaint Office.
More than 19,500 allegations of maltreatment came to the state through these reports in 2013. That number represents a 527 percent increase in the number of maltreatment allegations since 2010.
"It tells that people aren't trying to hide something. They're not waiting for a complaint or a family or community member," Beardsley said of the number of self-reports. "They're saying 'Hey, we caught something or something less than desirable happened. We are going to do our own internal investigation, and we believe it's appropriate and required for an external agency to look at it.'"
A majority of allegations involve neglect both regionally and statewide.
In the six northwestern counties, 36 of the 58 complaints filed in the past decade were allegations of neglect.
Another 11 complaints were filed alleging abuse, six for financial exploitation and the remaining five for other violations in those counties.
Statewide, 60 percent of all allegations accused providers of neglect in 2013, according to the annual maltreatment report. The report added 45 percent of investigations conducted on site confirmed neglect did occur.
Confirmed cases of neglect in the northwest county reports range from unsupervised residents falling, falls not being reported and a lack of general care.
In one case, staff at McIntosh Manor in McIntosh, Minn., failed to notify a physician after blistered areas on a male resident's genitals opened and bled, according to the state incident report. Over a period of about two weeks, the blisters worsened, the resident began running a temperature, lost consciousness and died on May 28, 2006.
"This lack of communication with the physician represents a facility system breakdown that placed all facility residents in immediate jeopardy if they were to become ill," Norling wrote in her report.
In the 10-year period, a Herald analysis shows McIntosh Manor received the most complaints of any facility in the six-county area with seven complaints filed and six substantiated. The six confirmed allegations occurred from 2005 to 2007. The most recent complaint was lodged in 2010, and an investigation was inconclusive.
McIntosh Manor officials did not return requests for comment.
REM Northstar facilities in East Grand Forks and Crookston saw a total of six complaints with one confirmed.
Oakland Park Communities in Thief River Falls also saw six complaints with two substantiated cases. Oakland Park Communities staff did not return requests for comment.
One growing area of concern for state and facility officials is an increasing number of financial exploitation cases involving medication theft.
"There clearly is a trend out there of people stealing drugs," Beardsley said. "These places need to tighten their oversight on narcotics."
Allegations of financial exploitation jumped 556 percent from 2010 to 2013 in Minnesota.
One recent financial exploitation investigation resulted in criminal charges being filed against a former nurse at Villa St. Vincent in Crookston accused of taking painkiller patches off residents, placing them on his tongue and placing them back on residents later.
David Matthew Perala, faces felony theft charges in Polk County as a result of the incident, which was reported to the state by the nursing home this past summer, investigated by state officials and then turned over to the Polk County Attorney's Office.
Villa St. Vincent officials did not return requests for comment made by the Herald.
At least one other confirmed case of staff taking medication occurred in 2006 at The Country Place Apartments, an assisted-living facility located in Erskine.
Within a two-week period, the staff member took 10 Tylenol No. 3 and 21 Vicodin pills from a patient.
As part of Care Providers of Minnesota conference and events, Beardsley said police and pharmacists are brought in to educate facility staff about drug theft trends in health facilities.
Whether it's staff stealing medicine or any other type of maltreatment, the investigation process for health facility complaints can begin a number of ways, most commonly through facility self-reports.
Once an allegation is received, an initial investigation is done by the office to ensure the complaint has been sent to the right department. During that time, office staff also make the determination if a site visit by an investigator is necessary.
A site visit is unannounced and is used to gather evidence through interviews, medical records and other documents. The Minnesota Department of Health declined to make an investigator available for this story.
Investigations into these claims can range anywhere from days to months. Of those complaints filed in northwest Minnesota counties in that 10-year period, the shortest investigation was completed in two days while the longest stretched to 351 days.
Allegations are considered substantiated if 50 percent or more of the evidence indicates a violation occurred.
At the conclusion of an investigation confirming maltreatment, a report is compiled that does not include the identity of victims, staff or perpetrators and is shared with the complainant and the facility. The state also may forward reports to law enforcement, the state Board of Medical Examiners, the state Board of Nursing and the county attorney.
Those entities can revoke individuals' licenses or press criminal charges if the case warrants it.
Facilities cited by the state for violations can result in the state not renewing, suspending or revoking the facility's license to operate.
To Beardsley, each complaint lodged or each incident uncovered by internal investigations presents an educational opportunity.
"People and systems make mistakes," Beardsley said. "The challenge is to learn from them and improve."