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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.” On June 18, 2025, most of the children and family work, including investigations of maltreatment at childcare centers, at the MN Department of Human Services (DHS) Office of Inspector General transferred to the new Minnesota Department of Children, Youth, and Families (DCYF), as directed by state law. While this investigation began under DHS, pursuant to Minnesota Statutes, section 15.039, subdivision 2, this Investigation Memorandum is being issued by DCYF pursuant to that transfer.
License Number and Program Type: 809653-CCC (Child Care Center) Investigator(s): Judie Schwanke Minnesota Department of Children, Youth, and Families 651-539-8268 Suspected Maltreatment Reported: It was reported that an alleged victim’s (AV) fingers were burned when a staff person ran a steam mop over his/her hand while mopping the classroom floor. Date of Incident(s): June 12, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 27, 2025; from documentation at the facility and through five interviews conducted with the AV’s family member (FM1 and FM2), a supervisory staff person (P1), and two facility staff persons (P2) and the SP. Facility documentation showed the AV was nine months old and enrolled in an infant classroom at the time of the incident. The facility was attached to an assisted living facility and had multiple classrooms including two infant classrooms. The infant 1 classroom was rectangular with a hard floor. On one half of the floor were connected foam tiles and on the other half of the floor was a small rug. In between the foam tiles and the rug was a small “aisle” of hard floor. The facility used a Shark Steam Mop to clean the hard floor. The facility used a mobile application (app) platform used to communicate with families and streamline administrative functions. FM1 stated that s/he did not recall the date of the incident but on that day, s/he received a phone call from the SP right after the incident. The SP told FM1 that as s/he cleaned the classroom, s/he moved the AV and the AV put his/her hand under a mop and got “scraped.” The SP did not tell FM1 that the mop was a steam mop and FM1 and FM2 thought that the incident was a “semi unavoidable accident.” FM1 told the SP that s/he was just about to leave and pick up the AV and would be there in a “couple of minutes.” Approximately 15 minutes later, FM1 arrived at the facility. The AV was “crying a little bit,” and “seemed fussy.” The middle finger of the AV’s left hand looked like it had a “blister that had burst,” and the pinky, ring and pointer finger “all had blisters” that covered the top portion of the AV’s fingers. The SP told FM1 that s/he used a steam mop and it went over the AV’s hand. At home, FM1 gave the AV Tylenol and the AV used his/her hand to eat and was able to move his/her fingers. FM1 and FM2 did not seek medical care for the AV. The AV was “fussy” through the night. The next morning, the blisters on the AV’s fingers were “bigger” and were approximately the size of a “pencil eraser.” FM1 applied a “triple antibiotic” and aloe from an aloe vera plant to the blisters. After almost two weeks, the AV’s fingers were “ a little red and “pretty much healed.” On September 23, 2025, FM1 and FM2 went to the facility and watched video footage of the incident. FM2 stated that the SP made “no attempt” to remove the AV from the path of the steam mop. Prior to this incident, the FM1 and FM2 did not have concerns with the facility. An incident report dated June 12, 2025, written by the SP stated that while s/he was “steam mopping” in the infant 1 classroom, s/he moved the AV “out of the way” and the AV “rolled in the way” and “stuck” his/her finger “under.” There was “no blood” present, “just scraped skin.” An ice pack was placed on the AV’s left hand and the AV’s hand was placed in a “bowl of milk.” An incident report dated June 12, 2025, written by P1 stated that while the SP was “steam mopping” in the infant 1 classroom, the SP moved the AV “out of the way.” The AV then placed his/her hand “back down” and the SP ran the steam mop over the AV’s left hand. The AV “instantly” began to cry and the SP picked up the AV. An ice pack was placed on the AV’s left hand and the AV’s hand was placed in a “bowl of milk.” The facility provided photos of the AV’s left hand taken on June 12, 2025, at 4:57 p.m. The photos showed the first layer of skin sloughing off the AV’s middle finger between the first and second knuckle. There was a white “C” shaped line above the first knuckle on the AV’s pointer finger. App communication for June 12, 2025 provided the following information: · At 7:26 p.m., one of the FM’s family members sent a message in the app to the facility. The messge stated that the AV’s incident report, written by the SP, was “incorrect.” The AV’s finger was not scraped and “all four fingers” on the AV’s left hand were “burnt.” The finger that was identified as having a scratch was “actually a burst burn blister,” and the AV’s other three fingers were “blistering pretty bad.” · The family member wrote that a steam mop should never be used in a classroom when children were present. · At 7:29 p.m., the family member sent a picture of the AV’s left hand. From the first knuckle to the tips of the nail bed of the AV’s four fingers on his/her left hand were reddish-brown. The pointer finger had a blister between the second knuckle and the nail bed. The middle finger had pink skin between the first and second knuckle and the sloughing skin was gone. The ring finger had a blister between the first and second knuckle. · At 8:09 p.m., a facility administrator replied that after reviewing the situation and speaking to staff persons involved, it was “clear” that the original report, written by the SP, did not “accurately reflect” the incident. During a staff meeting that evening, it was “reiterated” that steam mops were never to be used around children. P1, P2, and the SP provided the following consistent information: · On June 12, 2025, at approximately 5 p.m., P2 and the SP were in the infant room with between two and four children, including the AV. Either the SP or another staff person brought the steam mop into the classroom. The SP plugged in the mop and mopped a section of the floor for approximately two to three minutes” before moving to the area between the rug and tiles. The SP stated that the AV was sitting in the “aisle,” so s/he picked up the AV and moved him/her away and then mopped in the “aisle” between the tiles and the rug. The mop “rolled” over the AV’s hand and the AV “pulled” back his/her hand and looked up at the SP and made a gesture for the SP to pick him/her up. The AV cried and the SP did not know what happened. · The SP picked up the AV and looked at the AV’s left hand. S/he saw an “inch long scrape” from the first to second knuckle on the AV’s left middle finger. The SP did not see marks on the AV’s other fingers on that hand. The SP stated that at the time it did not “register” with him/her that the AV’s hand was burned and it “developed” into a burn.
· The SP stated that the steam mop had a pad on it and hot water seeps through the pad. On the day of the incident, the SP saw “steam” coming from the mop and the mop got “very warm.” The SP stated s/he believed the AV “scraped” his/her finger on a ledge on the underside of the mop. · P2 stated s/he looked at the AV’s hand and “knew right away” that the AV’s hand was burned. The AV’s “pinky” finger and “thumb” were “fine.” The AV’s pointer and ring finger were “red.” The AV’s middle finger had skin “peeled off,” and the AV grabbed at clothing and was rubbing his/her hand on “everything.” P2 stated that the AV was “hysterical.” · P1 was in his/her office and heard the AV cry for a “few minutes,” and when the AV did not stop crying P1 and P2 each stated that P1 went to the infant 1 classroom to see if s/he could “assist.” The SP stated s/he “immediately grabbed” the AV and ran the AV to the office and asked P1 what s/he should do because the AV’s hand was “scraped.” · P1 stated that when s/he arrived at the infant 1 classroom P2 was feeding another child, the SP was holding the AV, and the steam mop was off and propped up near a gate in the classroom. P1 stated that the SP told him/her that while the mop was propped up and off, the AV put his/her hand under the mop head and “scraped it.” P1 asked the SP if s/he had called the FM and the SP told P1 that s/he had not called yet. P1 directed the SP to call the FM “right away.” P2 stated that the SP called the AV’s FM but did not hear what the SP told the FM. · The SP stated s/he called one of the AV’s family members and told him/her that the AV’s hand had gotten “scraped” under the steam mop and that the AV was given first aid. The family member told the AV that s/he was on his/her way to pick up the AV. · P1 looked at the AV’s hand and saw that it was red and some skin on the middle finger was gone and “looked like scraped skin.” The AV would not calm down and his/her hand “became more red.” P1, with the SP, took the AV out of the infant 1 classroom and brought the AV to the infant 2 classroom. P1 held the AV and stood near a window to calm the AV. The AV rubbed his/her left hand on P1’s shirt and then cried. Another staff person looked at the AV’s hand and thought that the injury looked like a burn and got a bowl of cold milk to put the AV’s hand into to cool the burn. · Between 5 and 5:05 p.m., P1 sat the AV at a table and placed the AV’s left hand in the bowl of milk for a “minute.” The AV’s body “shook” and P1 did not “feel comfortable” with that so s/he removed the AV’s hand from the milk and “dabbed” the injury with a “soft bib dipped in milk”. · P1 told the SP that the AV’s injury was “turning into a burn,” and the SP told P1 that the AV “must have” touched the mop while it was “wrapped up” and “cooling.” · The SP took the AV back to the infant 1 classroom and held the AV’s hand in the bowl of milk because that seemed to “sooth” and “relieve the pain a little bit.” The SP completed an incident report and in it wrote that the mop “rolled over” the AV’s left hand. The SP stated that at the time s/he did not know that the mop burned the AV’s hand. The SP stated that in “hind sight,” s/he should have had someone read through the report before it was sent to the FM via the app. · At 5:07 p.m., P1 watched video footage from the infant 1 classroom. P1 saw that the SP steam mopped the floor while children were “playing on the floor.” The SP moved the AV and the AV put his/her hand on the floor and the SP “ran over it” with the steam mop. · The SP stated that the AV cried until the FM arrived at the facility at approximately 5:30 p.m. The SP handed the AV to the FM and told the FM that while the room was being cleaned the AV’s hand got underneath the steam mop and it had gotten scraped. The SP stated that at that time s/he was “hopeful” that the AV’s injury was not going to be a burn. · On June 13, 2025, between 10:30 and 11 a.m., P1 stated s/he talked with the SP. P1 told the SP that s/he watched the video footage and the incident report that the SP filled out was not accurate to what happened. The SP was “in tears” and said s/he did not know why s/he “told a different story” than what had actually happened. The SP told P1 that s/he was “scared.” The SP stated that during this conversation, P1 told him/her not to use the steam mop while children were present. · On June 13, 2025, the SP saw the AV’s hand and saw blisters on all of his/her fingers on his/her left hand. · P1 stated that on June 23, 2025, the AV’s hand looked “sunburned,” and where the AV’s skin had peeled, the skin was growing back. · P1 stated that staff persons were trained to clean classrooms when children had left for the day. During nap time, staff persons could clean at the opposite end of the room from where children slept. · P2 stated s/he was trained to clean when children were not present and felt his/her training was adequate. · The SP stated that s/he was trained to transition children out of a classroom before cleaning the classroom. On the day of the incident, s/he was the “last” infant staff person so the room could not be “clear” when s/he cleaned. The SP just had the AV and another non-mobile infant and s/he thought it would be “okay” to clean. The SP stated s/he had previously used the steam mop in the classroom with children present and had no incidents. S/he had not been told not to use the steam mop when children were present. The facility provided a 14 second video segment of the incident. The video was not time stamped and did not contain audio. At the beginning of the video, the AV sat on the floor next to a square toy. Half of the AV’s body was on the foam tiles and half of his/her body was on the hard floor. There was another infant in a low infant swing on the foam tiles. The SP walked toward the AV pushing the steam mop. P2 was behind and to the side of the SP. When the SP was next to the AV, s/he held the mop with his/her left hand, bent down and picked up the toy, and placed it on the foam tiles. The SP then pushed the AV’s left leg onto the foam tiles with his/her right hand. The AV’s bottom was partially on the foam tiles and partially on the hard floor and P2 walked to the infant in the swing and squatted down facing the AV. The AV put his/her left hand down on the hard floor. The SP moved the steam mop toward the AV and the mop covered the AV’s left hand. The AV lifted his/her hand and the SP continued to mop for three seconds. The SP then placed the mop on the floor and bent over the AV and the video ended. An untitled document, signed by P1 and the SP, stated that on June 12, 2025, the SP was using a steam mop during working hours while children were “actively playing” in the infant room and the SP “accidentally” ran the mop over the AV’s hand, “resulting in visible burns” to his/her fingers. The incident demonstrated “negligence in maintaining a safe environment,” and “dishonesty in reporting a critical safety issue.” According to burncenters.com, a scald burn is a burn caused by water such as cooking water, bath water, and steam. The temperature of steam is 212 degrees Fahrenheit. Signs and symptoms of a steam burn include redness, swelling, pain, skin peeling or sloughing, and blistering. A second degree steam burn is red, swollen with possible blistering. A third degree burn is pain-free and appears dry and tight and white. Instead of blistering, the skin peels or sloughs. This burn affects the skin and underlying tissue and may take months to heal. According to the Shark Steam Mop Manual, there was a danger of scalding with the steam mop use. Safety instructions included keeping the steam mop away from children, when in use, NEVER turning the steam mop over on its side or directing steam toward people, pets, or plants, and DO NOT put hands or feet under the steam mop. It gets very hot. The facility’s Safety Rules for Prevention of Accidents stated that “heat sources” in the classrooms were protected or located out of the reach of children to protect children from burns. The facility’s Risk Reduction Plan stated that steam mops and other hot cleaning items were used at “closing times” when children were not present. Facility documentation showed that P1, P2, and the SP were each trained on the Reporting of Maltreatment of Minors Act, the facility’s policies and procedures including the Safety Rules for Prevention of Accidents and Risk Reduction Plan. Relevant Rules and/or Statutes Minnesota Statutes, section 142B.54, subdivision 2, paragraph (e) and Minnesota Rules, part 9503.0140, subpart 17, states that hazardous objects must be stored out of the reach of children.
Conclusion: A. Maltreatment: Consistent information was provided that on June 12, 2025, the AV was in the infant 1 classroom with the SP when the AV put his/her hand on the floor and the SP put the steam mop over the AV’s hand. The SP stated s/he moved the AV out of the aisle to steam mop the floor when the AV placed his/her hand on the floor and the SP rolled the steam mop over the AV’s left hand. The AV sustained burns on the four fingers on his/her left hand. The SP’s action of using the steam mop, which reached temperatures of 212 degrees Fahrenheit, in a classroom with children present was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Children, Youth, and Families; a violation of the facility’s Safety Rules for Prevention of Accidents and Risk Reduction Plan; and a violation of Minnesota Rules 9503.0140 subpart 17. Although the AV’s burns did not require medical care, given that the SP used the steam mop in the classroom with children present which resulted in burns to the AV’s fingers and that the SP was trained to move children out of the classroom before cleaning, there was a preponderance of the evidence that the SP’s actions were not accidental and were a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so. B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was responsible for the care and supervision of the AV at the time of the incident and was trained on the facility’s policies and procedures as well as the Reporting of Maltreatment of Minors Act.d. The SP was responsible for the maltreatment of the AV. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Children, Youth, and Families for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an Internal Review and determined that their policies and procedures were adequate but there was a need for continued training on cleaning protocols and the Risk Reduction Plan. The steam mop was stored in the office and staff persons must verify with administrative staff before using the mop. All staff persons were retrained that cleaning was to be done at closing time when children were not present, this included the use of the steam mop. Action Taken by Department of Children, Youth, and Families, Office of Inspector General: The Department of Children, Youth, and Families informed the Department of Human Services, Office of Inspector General, Background Studies Division that the SP was determined responsible for maltreatment. The determination that the SP is responsible for maltreatment is subject to appeal. On November 5, 2025, the facility was issued a Correction Order for the violation outlined in this report. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Children, Youth, and Families.
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