A story of rape and mistreatment of an 89-year-old woman by staff members of a northern Minnesota senior living home has raised temperatures across the state. After completing its investigation, the Minnesota Department of Health (MDH) has held the individual caregiver, Andrew Scott Merzwski, 30, solely responsible, with no blame levied at administrators of the Edgewood Vista assisted living facility, despite the fact that they may have impeded the investigation — or so attorneys claim in court documents filed and reported by the Star Tribune.

The MDH verdict has caused concern, in part, because this particular instance of rape is not the only crime to have taken place at the nursing home. In December, the MDH substantiated allegations of multiple instances of theft at the facility. Edgewood Management Group, owner of the home, said in a statement that it cooperated with local and state authorities with regard to the rape investigation. The Group owns and/or operates a total of 42 independent living, assisted living, and memory care communities with a total of 2,500 beds in seven states.

The nightmare began, according to the Tribune report on court testimony, when the victim was preparing for bed in January 2013 and Merzwski entered her room. She invited him to sit down and watch a film with her. He then started taking his clothes off, so the woman pointed at a photograph of her husband and said, “It’s not right, this wouldn’t be right,” according to court testimony. Her words did not stop his advances. Afterward, the woman washed her sheets and underwear, which had blood on them.

The next morning, the woman reported the incident to her daughter, who immediately notified the police. Merzwski, then, admitted he had intercourse with the woman. Nevertheless, the woman was taken to St. Luke’s Hospital in Duluth, where she spent more than two days in a locked psychiatric ward while investigators tried to decide whether she was telling the truth.

Attorneys allege that administrators never informed the hospital that Merzwski had already admitted to having sex with the woman. Mary Salisbury, a sexual assault advocate who visited the victim at the hospital, said she had multiple conversations with Edgewood staff, but they never once told her about Merzwski’s confession. Nurse examiner Theresa Flesvig said in testimony filed with the court, “The room she was in was dark and cold … and they locked her in at night and all she had was a blanket.”

Eventually, Flesvig performed a complete examination for evidence of rape. Flesvig said the laceration that resulted from the rape was the “biggest tear” she had ever seen in her six years of work in the field. Days later, an administrator at Edgewood Vista appeared to defend the rapist even after his admission to police. Court testimony also holds that Marilyn Moore, clinical services director at the home, asked Flesvig, “Did she tell you that this was consensual? Did she tell you that she flirts with this boy mercilessly?” In a conversation with Salisbury, Moore reportedly said the elderly woman “was making it up,” and referred to her as a “flirt.”

Merzwski was sentenced to 53 months in prison last month. The MDH, which regulates more than 2,000 licensed care facilities in the state, began its investigation of this case 10 days after the rape occurred. In 2011, according to the Tribune, the department received 12,262 complaints of maltreatment and other incidents, but investigated only 1,023.