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August 24, 2026 CERTIFIED MAIL Antoinette Martindale, Authorized Agent Bluewater Residential Services LLC 925 East 4th Street Duluth MN 55805-2151 License Number 1072890-H_CRS (Home and Community-Based Services-Community Residential Setting) License Number 1072888-HCBS (Home and Community-Based Services) Report Number 202507423 DETERMINATION OF MALTREATMENT AND ORDER TO PAY A FINE Dear Antoinette Martindale: The Department of Human Services (DHS) determined that Bluewater Residential Services LLC, located at 203 High Street Apt B, Duluth, Minnesota, is responsible for maltreatment by neglect. Based on this determination, DHS is ordering you to pay a fine of $1000. Details of our findings are provided below and in the enclosed Investigation Memorandum for report 202507423. Our next steps and your options are also detailed. I. Determination of Maltreatment It was reported that a vulnerable adult (VA) died by suicide. There were concerns that facility staff persons did not sufficiently address the VA’s mental health symptoms and did not adequately supervise the VA. Based on the maltreatment investigation, DHS determined that Bluewater Residential Services LLC was responsible for neglect of the VA. See the enclosed Investigation Memorandum for more information. Legal Authority: Minnesota Statutes, section 626.557, subdivision 9c. Fine: $1000 Citations 1. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). Violation: For one person (P) whose record was reviewed, the license holder did not document in the medication administration record (MAR) as required. The license holder did not maintain documentation in the P’s medication administration record (MAR) of a notation of any occurrence of a dose of medication not being administered as prescribed, whether by error by the staff or by refusal by the P and when, and to whom the report was made. On June 16, 2025, the P’s MAR was missing a notation of whether the P’s medications were administered or not. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Violation: The license holder did not provide services in response to the person’s identified needs as required. The license holder maintained documentation in the P’s support plan addendum indicating the P would receive hourly check-ins by staff persons. The license holder did not provide services in response to P’s identified needs when they did not provide hourly check-ins by staff. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: The license holder did not provide orientation to individual service recipient needs as required. The license holder did not provide staff persons with an orientation to service recipient needs that included review and instruction on the person’s support plan or support plan addendum, and individual abuse prevention plan, as it relates to the responsibilities assigned to the license holder, to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: The license holder did not establish/enforce ongoing written individual abuse prevention plans as required. The license holder did not establish an accurate individual abuse prevention plan for P. During the P’s initial planning meeting, it was determined that the P was allowed four hours of unsupervised time in the community and it was implemented by staff persons. However, the P’s unsupervised time was not added to the P’s individual abuse prevention plan. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not ensure the designated coordinator and the designated manager provided program management and oversight of the services provided by the license holder as required. a. The license holder did not ensure the designated coordinator met the following responsibilities when they did not: · provide oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum. This is evident in citations 1, 2, and 4 and · provide instruction and assistance to direct support staff implementing the support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. This is evident in citation 3. b. The license holder did not ensure the designated manager met the following responsibilities when they did not ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2. Corrective Action Ordered: Within 30 days of receiving this order, you must develop and implement a plan that ensures that the designated coordinator and designated manager will perform the required duties above. On an ongoing basis, you must maintain compliance as required in these subdivisions. II. Order to Pay a Fine Because DHS determined that Bluewater Residential Services LLC is responsible for maltreatment you must pay a $1000 fine. Legal Authority: Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), subparagraph (4). Billing and Payment of the Fine DHS will send you an invoice for the $1000 fine. Payment must be made as directed on the invoice. If you request a contested case hearing, as described below, do not pay the fine at this time. After the contested case hearing, the Commissioner of DHS will issue a final order. Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is personally and jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine. III. YOUR RIGHT TO APPEAL You have right to appeal the maltreatment determination and/or fine. Please see options below. Should you exercise your rights to appeal send: 1.
Right to appeal the fine and maltreatment determination You have the right to appeal the fine and maltreatment determination. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 15 calendar days from when you received this order. See address Section III. If your request is being personally delivered, it must be received by DHS within 15 calendar days from when you received this order. See address Section III. Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order. 2. Request for reconsideration of the maltreatment determination only If you do not appeal the fine, you may still request reconsideration of the maltreatment determination. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to request reconsideration began when you received this order. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the maltreatment determination · Identify what is inaccurate or incomplete about the information in the Investigation Memorandum · Supply information that is accurate or more complete · State why you believe the finding of maltreatment should be changed · Be made before the deadlines provided below. Your request must be postmarked within 15 calendar days from when you received this order. See address Section III. A response to your reconsideration request will be mailed within 15 working days after DHS receives your request. You have the right to request a fair hearing if a response is not mailed within 15 working days. 3. Right to appeal the order to pay a fine only You have the right to only appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order. If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. See address Section III. If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. See address Section III. Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. After this hearing, the Commissioner of DHS will issue a final order. 4. Legal representation at the contested case hearing You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.justice4mn.org to find a local legal services program that may be able to help you. You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license. · Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4), item (i) provides that DHS may impose a $1000 fine for each determination of maltreatment of a vulnerable adult under section 626.557 for which the license holder is determined responsible. · In determining whether the facility, an individual, or both are responsible for substantiated maltreatment, DHS must consider the mitigating factors provided in Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c). · Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license. · License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612. · License holders have a right to request reconsideration of a maltreatment determination, under Minnesota Statutes, section 626.557, subdivision 9d. · Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent. · Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies. Questions If you have any further questions regarding this matter, you may contact Melanie Bridges, Supervisor, at 651-431-6559. Sincerely,
Maggie Hanson, Intake & Investigations Unit Manager Licensing Division Office of Inspector General Enclosure
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