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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.”
License Number and Program Type: 1011982-CCC (Child Care Center) Investigator(s): Tessa Ripka & Kimberly Anderson Minnesota Department of Children, Youth, and Families 651-539-8226 Suspected Maltreatment Reported: It was reported that five alleged victims (AV1, AV2, AV3, AV4, and AV5) were injured during “bubble day” when they stepped on a pipe sticking out of the ground that cut their feet. AV1 needed stitches to his/her foot. Date of Incident(s): July 21, 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 August 7, 2025; from documentation at the facility and medical records; and through nine interviews conducted with three facility staff persons (SP1, SP2, P), AV2, AV3, AV1 and AV2’s family member (FM1), AV3’s family member (FM2), AV4’s family member (FM3), and AV5’s family member (FM4). AV1, AV4, and AV5 were not at the facility on the date of the site visit. The facility was in a large building. There was a fenced grassy courtyard area in the front of the building that was not typically used as a play area.
AV1 was nine years old, AV2 was six years old, AV3 was ten years old, AV4 was seven years old, and AV5 was nine years old at the time of the incident, and all were enrolled in the school age classroom. AV2 said there was something sticking out in the grass during bubble day and s/he stepped on it. AV1 also stepped on something. It hurt and AV2 asked for help. It was on the bottom of his/her foot and was bleeding a little bit. Staff persons put a paper towel on it. AV3 and AV4 also got cuts on their feet. AV1 needed stitches for his/her cut. The children did not have shoes on because it was bubble day. The staff persons told the children to take off their shoes and socks. The class came inside after the children got hurt. AV3 said it was hard to see the ground because there were so many bubbles. AV3 felt something on his/her foot, and it started to hurt “really bad.” When AV3 looked down at his/her toe it was “covered” in blood. There was one little cut that was bleeding on AV3’s foot. Staff persons wiped it, disinfected it, and put a band aid on it. AV1 got a “hole” in his/her foot and had to get stitches. AV2 got cut on both of his/her feet and another child got cut on the top of his/her foot. Later it started raining and the bubbles went down. Staff persons could see a pipe sticking out of the ground. After the children got hurt, staff persons told the children to leave the playground because they thought it was something that was coming from the bubble machine. There was not a rule that the children could not take their shoes off, but after that there was a rule that the children had to keep their shoes on. SP1-SP2 provided the following information: · On an unspecified date at approximately 10:30-11:00 a.m., the school age class was outside in the area in front of the building for “bubble day” with SP1 and SP2. There was a machine that blew bubbles, and the children played in them. The area in front of the building was not a typical area that the children played in but was used for this special day. The school age class was not the first class to use the area, so the bubbles were already covering much of the ground when the school age class arrived. · SP1 told the children to take their shoes off before going out for bubble day as s/he did not want their shoes to get wet. SP1 said that s/he was “never” told that the children could not take off their shoes for water or bubble days. SP2 said that normally the children wore water shoes for water or bubble day but SP1 told the children to take their shoes off that day. SP2 said s/he thought afterward that s/he should have had the children put on water shoes. · After the class played for approximately 10-15 minutes, AV3 limped out of the bubble area over to SP1. SP1 asked if AV3 twisted his/her ankle and AV3 said that s/he scratched him/herself. AV3 had a 2-inch scratch that was bleeding “a little” on the top on his/her foot. SP1 got some supplies to clean the scratch and applied a band aid. · Within five minutes, AV4 approached SP1 and SP2 with an injury, followed by AV1 and AV2. SP1 said that AV4 had a cut on his/her ankle that was bleeding. SP2 said that AV4 had a cut on the bottom of his/her big toe that was an inch long. AV2 had a small cut that SP1 said looked like a “piece of grass.” AV1 was screaming and his/her foot was bleeding. AV1 would not let staff persons look at his/her foot. SP1 called the P to come and see what had happened. · SP1 walked over to the bubble area to see what was causing the injuries. The whole yard was filled with bubbles, so s/he could not tell what was causing the injuries. The person in charge of the bubble machine asked what was wrong and SP1 said that children were getting hurt so they were going to go inside. · SP1 and SP2 brought the children back inside the building and got all the cuts cleaned and bandaged except for AV1. AV1 finally let SP1 and SP2 see his/her injury, and it looked like something had punctured his/her skin on the bottom of his/her foot. AV1 could not tell staff persons what happened. Staff persons called FM1 to pick up AV1. AV1 was taken to a medical provider and received stitches. The P said that sometime between 10:30-11:00 a.m., s/he was called outside by SP1 and SP2 to look at a cut on AV3’s foot. It looked like a small scrape, so the P said to write a report and let FM4 know. The P noticed that the children did not have any shoes on which was against policy and told staff persons to make sure they had the children put their shoes on. The P went back inside and shortly after was called to the classroom to look at AV1’s foot. AV1 had a cut on his/her foot that looked “pretty deep.” The P took a photo to send to FM1 and called him/her. FM1 came to pick up AV1 and AV2 and said that there was an exposed pipe in the front lawn. The P then wrote up a maintenance request to get the pipe fixed. Each morning, staff persons did a sweep of the playground area but the P did not think to do a sweep of the front lawn area as this was not a place that children typically played. If children did not have extra shoes or water shoes, they were not to participate in water activity. FM1 said that on July 21, 2025, s/he got a call at approximately 12 p.m., that AV1 was injured at the facility. The facility shared a video showing a cut to AV1’s foot so FM1 went to pick up AV1. AV1 needed stitches on his/her right foot. AV2 also had a cut on his/her foot that did not require medical attention. AV1 and AV2 said the staff persons told the children to remove their shoes before going outside. FM1 had concerns that the facility did not check the area to ensure there was nothing dangerous prior to letting the children play there and that the facility had the children remove their shoes. FM1 did not understand how multiple children were injured before the activity was stopped and felt the activity should have stopped after the first child was injured. FM2 said that AV3 told FM2 that s/he had stepped on something during bubble day and cut his/her foot. AV3 had a puncture type wound smaller than a quarter on the ball of his/her foot. FM2 asked for but was not provided with an incident report about the incident. When the facility had water or bubble days, they sent out a message to bring extra clothing or a swimsuit. FM2 was not sure whether children typically took their shoes off for bubble days. FM3 said in July 2025, during bubble day, AV4’s foot fell into an exposed drainpipe and was cut. AV4 was bleeding “everywhere,” but staff persons did not stop the activity until three or four more children were injured. The children were not wearing shoes and FM3 thought they were supposed to wear shoes. The P told FM3 that they did not inspect the front lawn before having the bubble machine outside because they did not know it was going to be on the front lawn. AV4 had a large cut on his/her ankle. FM4 said that on an unspecified date, AV5 said that his/her foot hurt after returning from the facility. AV5 had a half inch cut on his/her left foot on the bottom and around the toe. AV5 said it happened at the facility when they were playing in the bubbles. Staff persons told the children to take off their shoes. AV5 said it felt like s/he was cut on something metal in the bubbles. FM4 did not think the children had ever taken their shoes off for water or bubble day prior to that incident. When the facility sent messages about sending water clothes and shoes, FM4 always sent sandals or water shoes with AV5 to wear outside. The Incident/Accident Report for Parent/Guardian showed that on July 21, 2025, at 11:15 a.m. AV1 cut the bottom/middle of his/her right foot. Staff persons tried to clean the cut but AV1 declined. Staff persons called FM1. At 11:20 a.m., AV2 got a small scrape on the bottom of his/her left foot. The foot was washed, and a band aid was applied. No incident reports were found for AV3, AV4, or AV5. FM1 provided photos that showed an approximately one to two inch long cut on the bottom of AV1’s right foot near the arch. Another photo showed a thin 2 inch cut on the bottom of AV2’s right foot near the arch. Two final photos showed a white drainage type pipe sticking out of the grass slightly with an unfinished edge. FM3 provided photos that showed an approximately three-to-four-inch scrape/cut on AV4’s right shin just up from his/her ankle. There was an approximately two-inch scratch on the top of AV4’s right foot near the toes. Hospital records showed that AV1 was seen at the emergency room on July 21, 2025, for a right foot laceration on the sole of the foot. AV1 received four sutures which were to be removed in ten days and antibiotics to be taken for ten days. The Family Handbook stated that shoes were required for all walking children. Family members were to provide two complete sets of extra clothes, and an extra set of shoes was encouraged. The facility’s Safe Summer Footwear policy stated that children were to wear rubber soled, closed toed shoes with a closed heel or heel strap at the facility. Facility documentation showed that prior to the incident, SP1, SP2, and the P were each trained on the facility’s policies and procedures, “Summer Safety,” and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute: Minnesota Rules, part 9503.0110 subpart 3, item C, states that facility policies must contain procedures for the daily inspection of potential hazards. Conclusion: A. Maltreatment: Information was consistent that on July 21, 2025, the school age class played barefoot in the fenced in grassy courtyard in front of the building. AV1, AV2, AV3, AV4, and AV5 all received cuts to their feet and legs after stepping on an exposed drainage pipe that had an unfinished edge. SP1 said that s/he told the children to remove their shoes before going outside to play in the bubbles. SP2 said that s/he thought afterward that s/he should have probably had the children put on water shoes before playing in the courtyard. SP1 and SP2 were unable to inspect the play area before the class used the courtyard because bubbles were already covering the area after several other classes had already been out to play. The P said that it was facility policy for the children to wear shoes during bubble and water days and that the playground was supposed to be inspected every morning, but the front courtyard area was not inspected because it was not an area that children typically played in. Given that children were not wearing shoes per facility policy; that the play area had not been inspected, which was a violation of Minnesota Rules, part 9503.0110 subpart 3, item C; that the area contained a pipe with sharp edges; and that AV1, AV2, AV3, AV4, and AV5 each sustained cuts on their feet/legs from the drainage pipe; there was a preponderance of the evidence that there was a failure to supply AV1, AV2, AV3, AV4, and AV5 with necessary care; and a failure to protect AV1, AV2, AV3, AV4, and AV5 from conditions or actions that seriously endangered AV1, AV2, AV3, AV4, and AV5’s physical or mental health; when reasonably able to do so. It was determined that neglect occurred (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). 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. Multiple class groups at the facility used the grassy courtyard on the day of the incident. This area was not daily inspected for hazards, which was a violation of Minnesota Rules, part 9503.0110 subpart 3, item C. SP1 and SP2 were trained on the facility’s policies, “Summer Safety,” and the Reporting of Maltreatment of Minors Act prior to the incident. SP1 and SP2 were responsible for AV1 – AV5 care at the time of the incident, and each allowed the children to play outside without shoes on. In addition, SP1 and SP2 did not halt barefoot play in the courtyard until five children were injured. After consideration of the above, the facility, SP1 and SP2 were each determined responsible for maltreatment of AV1, AV2, AV3, AV4, and AV5. 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. 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. It was determined that the substantiated neglect for which the facility was responsible was “serious” maltreatment because AV1’s injury required medical treatment (sutures and prescription medication). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed when the children did not wear shoes outside and no playground inspection was completed. The exposed pipe was repaired. All staff persons were retrained on related policies. The staff persons involved in the incident no longer worked at the facility. 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 SP1 and SP2 were determined responsible for maltreatment. The determination that SP1 and SP2 were responsible for maltreatment is subject to appeal. On June 29, 2026, the license holder was ordered to forfeit a fine of $5,000 as a result of the substantiated serious maltreatment for which the facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal. 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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