raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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.”

Report Number: 202407409

Date Issued: April 23, 2025

Name and Address of Facility Investigated:

Nexus East Bethel Family Healing
900 189th Ave NE
East Bethel, MN 55011

Disposition: Maltreatment determined as to neglect of an alleged victim with inconclusive responsibility.

License Number and Program Type:

1119782-CRF (Children’s Residential Facility)

Investigator(s):

Carla Harvieux
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
carla.harvieux@state.mn.us

651-431-6616

Suspected Maltreatment Reported:

It was reported that two staff persons (SP1 and SP2) supervised an alleged victim (AV) who had one to one supervision because s/he threatened to harm him/herself. There was a miscommunication between the SPs, and the AV was unsupervised in his/her bedroom for a few minutes and tied a hoodie around his/her neck. When the SPs located the AV, s/he was “turning blue,” but recovered when the hoodie was removed.

Date of Incident(s): August 17, 2024

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 September 13, 2024; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P3, SP1, and SP2). The AV declined to complete an interview with this investigator, but s/he provided information to P1, who was an administrative staff person, which was included below. A staff person (P2) who was on shift when the incident occurred, initially agreed to complete an interview with this investigator, but did not respond to additional attempts to contact him/her.

The facility provided individualized, trauma informed psychiatric residential treatment (PRTF) services to youths ages 10-19 who had significant mental and behavioral health concerns. The facility had a video recording system that recorded common areas of the facility, but there were no cameras in the youths’ bedrooms or in the offices/rooms used for therapy or counseling at the facility. However, cameras in the hallway outside the AV’s bedroom recorded the locations/actions of staff persons outside the bedroom. At the time/date of the incident, the doors to the bedrooms on the unit in which the AV resided were locked when youths were outside the bedrooms, and staff persons kept the keys to the doors with them.

The facility’s Suicidal Ideation and Gesture Protocol showed that when youths were shadowed by staff persons, they were to be close enough to the youths to initiate a hold/intervention if needed, which meant that staff persons were to be in the same room with the youth, have eyes on the youth or have continued verbal contact with the youth when s/he was in the bathroom or shower. The shadowed youth was not to remain in his/her bedroom with the door closed unless s/he was changing clothes, and then staff persons were to keep verbal contact with him/her. When shadowed youths slept, staff persons were to remain awake in the hallway outside their bedrooms, and they were not allowed to use facility headphones when staff persons shadowed them for self-injurious behavior.

Facility documentation showed that the AV was diagnosed with adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, anxiety, and attention deficit hyperactivity disorder. The AV had a history of engaging in self-injurious behaviors and was being shadowed by staff persons at the time of the incident, but s/he wanted to “be off” staff person shadow. The AV had frequently declined to take his/her prescribed medications since s/he began residing at the facility in late July of 2024, and the Columbia Suicide Severity Rating Scale forms completed for the AV showed that s/he had thoughts of harming him/herself but did not have a specific plan to do so. When the AV was upset, s/he might give one-word answers, say s/he did not know, or shake his/her leg. The AV was friendly but might have difficulty adjusting to new surroundings.

Interviews with P1, P3, SP1, and SP2 with this investigator, facility documentation, and the facility’s Internal Review, provided the following:

· P1 said that on the date of the incident, the AV was to be shadowed by staff persons which meant that staff persons were to be close enough to him/her to intervene if the AV attempted to harm him/herself. The AV had an increased level of supervision because s/he recently made statements indicating that s/he intended to harm him/herself. Staff persons met at the beginning of each shift to discuss the needs of the youths, and on the date of the incident but prior to it, staff persons caring for the AV met to discuss the AV’s needs. SP2, who was a team lead, verbally instructed SP1 to shadow the AV during the shift. It was possible that instructions designating SP1 as the AV’s shadow were written on a white board in the unit office, but the white board was erased at the end of the shift or the next day. However, P1 had no firsthand information regarding staff shadow assignment, and thought that SP1 was shadowing the AV because SP2 said that s/he was. At about 4:40 p.m. on the date of the incident, the AV asked to go to his/her bedroom and SP2 opened the door which permitted the AV to enter his/her bedroom.

· Video from the facility’s recording system showed that at 4:38 p.m., the AV went to his/her bedroom, and that SP2 opened the door for the AV to enter the bedroom. SP2 remained near the bedroom door and called SP1 to the bedroom to assist him/her. At 4:39 p.m., the SPs entered the bedroom with the AV and were either in the bedroom or in the hallway, until 4:42:43 p.m. when SP2 exited the bedroom and walked alone toward the common area, then walked through a door, and entered another part of the facility out of range of the camera that recorded the hall/AV’s bedroom. SP1 remained inside the bedroom.

· At 4:44:15 p.m., SP2 re-entered the common area, and walked toward the AV’s bedroom, then entered it. The AV’s bedroom door was open. At 4:44:44 p.m., the AV and SP2 talked at the AV’s bedroom doorway, and at 4:44:54 p.m., SP1 exited the AV’s bedroom, walked past SP2 who was still standing near the AV’s bedroom doorway, and walked away from the AV’s bedroom toward the common area. Then at 4:44:59 p.m., SP2 walked away from the AV’s bedroom while the AV was standing in the doorway. SP1 and SP2 were both in the hallway walking away from the AV’s bedroom at the same time, and SP2 was about 20 steps behind SP1. Both were walking toward the common area in the same direction and SP2 would have seen SP1’s back as they walked toward the common area.

· At 4:45:02 p.m., while both SPs were walking away from the AV’s bedroom, the AV closed his/her bedroom door and was unsupervised inside his/her bedroom. SP1 stopped in the hallway and looked in a closet, and at 4:45:08 p.m., SP2 passed the closet and was about two to three feet behind SP1. The SPs continued walking into the common area, and at 4:45:11 p.m., SP1 turned to his/her left into another part of the facility and SP2 walked straight through the common area into a different part of the facility. The SPs were out of view of the camera until 4:46:25 p.m., when SP1 re-entered the common area and went into a door to his/her left, out of sight of the camera. At 4:47:02 p.m., SP2 re-entered the common area and walked toward the AV’s bedroom.

· At 4:47:26 p.m., SP2 opened the AV’s bedroom door and observed the AV with the hoodie tied around his/her neck. SP2 entered the bedroom, and shortly after that, P2 walked toward the AV’s bedroom and entered it, followed by P3. At 4:50:30 p.m., SP2 and P2 exited the AV’s bedroom and stepped into the hall, then walked toward the common area. P2 was carrying a dark colored garment in his/her hands. P3 remained with the AV, and SP2 and P2 each entered other parts of the facility out of the camera’s view.

· At 4:51:10 p.m., SP1 re-entered the common area with several youths, who walked toward the bedrooms, and SP1 opened the door that SP2 had just entered and appeared to speak with someone out of sight of the camera. SP1 then joined the youths in the hall near the bedrooms and entered the AV’s bedroom, while the youths remained in the hall. SP2 came into the camera’s view in the common area, and talked on a mobile phone, while P2 walked back and forth in the hall near the AV’s bedroom.

· At 4:52:36 p.m., the SPs talked in the hall outside the AV’s open bedroom door. SP1 remained in the hall outside the AV’s bedroom door, and SP2 walked back and forth in the hall talking on the phone. The AV remained inside his/her bedroom and the video ended about two minutes later. No information showed that the AV required medical care after the incident or that first responders were called.

· SP1 said that on the date of the incident, the AV was on staff shadow but there was a lot going on, and there were not enough staff persons to support the youths who needed assistance. SP1 was unsure who was assigned to shadow the VA but knew that it was not him/her and thought that SP2 was probably assigned to shadow the AV on the date of the incident. SP1 recalled that s/he and SP2 were talking with the AV in his/her bedroom, when SP2 exited the AV’s bedroom to help with other youths. The AV seemed to regulate him/herself but wanted SP2 to return to the AV’s bedroom so s/he could talk more with him/her. SP1 told the AV to “hang on” and said that s/he would get SP2 to return to the AV’s bedroom, but as soon as SP1 exited the AV’s bedroom and began walking away from it, the AV closed the bedroom door. SP1 stated that s/he thought that a couple of seconds later, s/he met SP2 walking toward him/her in the hall, and s/he remembered SP2 walking to the AV’s bedroom door and unlocking it. When SP2 opened the AV’s bedroom door, SP1 was in the hall with the other youths and did not see the AV but was later told that the AV put something around his/her neck. SP1 stated that s/he did not realize that the AV was unsupervised in his/her bedroom with the door closed.

· SP1 thought that there was a miscommunication between him/herself and SP2 regarding the AV’s supervision and thought that s/he was being blamed for the incident when all staff persons were responsible for supervising the AV when the incident occurred. In addition, prior to the incident with the AV, P2 told SP1 that s/he needed SP1 to assist him/her outside with the other youths and said, “God damn it [SP1],” and “Jesus Christ [SP1].” SP1 told SP2 that P2 was not being supportive and SP1 felt that s/he was pulled in many directions.

· SP2 stated that on the date of the incident, s/he instructed SP1 to shadow the AV during his/her shift. The AV asked to go into his/her bedroom, but SP2 knew that the AV seemed anxious and called SP1 to go into the AV’s room with the AV and SP2. The SPs talked with the AV, and s/he seemed to calm, so SP2 told SP1 that s/he would be right back and left the AV with SP1 while SP2 took a few outdoor recreation items and went into a courtyard at the facility with other youths. SP1 was out of SP2’s sight during this time, but when SP2 was with the youths, s/he counted them and realized that the AV was not in the group, then went to the AV’s bedroom, where s/he found the AV with a hoodie tied around his/her neck.

· SP2 immediately began untying the hoodie, but the AV held the hoodie with his/her hands to prevent SP2 from removing it, and SP2 called P3 for assistance. P3 entered the bedroom and held the AV’s hands, which permitted SP2 to untie the hoodie and remove it from the AV’s neck. The AV’s face was turning blue, but his/her normal color returned, and s/he breathed normally when the hoodie was removed. The AV was assessed by a facility health care professional (HCP) and a mental health care professional (MHCP), and s/he was moved to a bedroom that was closer to the common area of the facility to ensure that staff persons could supervise him/her more closely. There were no marks or injuries to the AV’s neck.

· P2 did not complete an interview with this investigator, and P3 said that s/he was unsure how the AV came to be unsupervised in his/her bedroom, but s/he responded to SP2’s call for assistance when the AV was found with clothing tied around his/her neck. P3 entered the AV’s bedroom and assisted SP2 to remove the hoodie from the AV’s neck then remained with the AV while SP2 made calls to supervisory/administrative staff persons regarding the incident.

The facility’s Staff Management Policy showed that the facility was to provide enough adequately trained staff persons to ensure that youth treatment needs were met. Nursing staff persons were to be available at all times, and during awake hours, there was to be at least one staff person to three youths within the living unit. During sleeping hours, there was to at least one staff person for every four youths within the living unit with the ability to access other staff persons within the facility as needed. Staff persons must remain awake overnight.

The facility’s employee scheduling software showed that SP1, SP2, P2, and P3 were working in the unit in which the AV resided at the time of the incident. SP1, P2, and P3 worked from 2 p.m. to 10 p.m., and SP2 worked from 3:30 p.m. to 10 p.m. Information from the facility showed that there were eight additional youths who resided in the same unit with the AV on the date/time of the incident. Excluding the AV and SP1 from the number of staff persons/youths present when the incident occurred, the staffing ratio was one staff person for each 2.67 youths.

The facility’s Suicidal Ideation and Gesture Protocol showed that if a youth expressed suicidal ideation or engaged in a suicidal gesture, staff persons were to ask the youth whether s/he had a plan, or had thought about how s/he might harm him/herself, and how likely s/he was to implement his/her plan to harm him/herself, then consider whether the youth had the means to carry out his/her plan/whether the facility could restrict the youth’s access to the means to carry out his/her plans. Staff persons were to support youths according to their plans, offer distress tolerance skills to the youths, complete an assessment of the youth using a Columbia Screen, and contact a mental health care professional (MHCP) or therapist for more guidance/support.

If the MHCP/therapist determined that staff persons should “shadow” a youth, staff persons were to be close enough to the youth to initiate a hold/intervention if needed, which meant that they should be in the same room or have eyes on the youths. Youths were not permitted to close their bedroom doors unless they were changing clothes. When shadowed youths slept, a staff person was to be in the hallway at all times. The need for staff shadow was reassessed every 24 hours, and youths were not removed from staff shadow unless it was approved by a MHCP.

The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident.

Relevant Statutes:

Minnesota Statutes, section 245A.04, subdivision 14, (b), (1-3), states that license holders shall provide training to program staff related to their duties in implementing the program's policies and procedures developed under paragraph (a); document the provision of this training; and monitor implementation of policies and procedures by program staff.

Conclusion:

A. Maltreatment:

On August 17, 2024, the AV was on staff shadow at the facility because s/he recently made statements that s/he intended to harm him/herself. Staff shadow meant that staff persons were to be close enough to the AV that they could intervene if the AV attempted to harm him/herself.

P1 and SP2 each stated that SP2 assigned SP1 to shadow the AV on the date of the incident when staff persons met prior to the shift, but SP1 said s/he was not assigned to shadow the AV on the date of the incident and thought that SP2 was shadowing the AV.

Video from the facility’s recording system showed that at about 4:38 p.m., the AV went to his/her bedroom, and that SP2 opened the door for the AV. At 4:39 p.m., SP2 called SP1 for assistance and the SPs were in the bedroom or in the hallway, until 4:42:43 p.m. when SP2 exited the bedroom and walked alone out of camera range. SP1 remained with the AV.

At 4:44 p.m., SP2 walked toward the AV’s bedroom and entered it. At 4:44 p.m., the AV and SP2 talked at the bedroom doorway, and at 4:44:54 p.m., SP1 exited the bedroom, walked past SP2 (who was standing in the AV’s bedroom doorway), and walked toward the common area. Five seconds later, SP2 walked away from the AV’s bedroom and the SPs were both in the hallway at the same time walking away from the AV’s bedroom. SP1 left first and SP2 was about 20 steps behind him/her. The SPs were walking in the same direction and SP2 was behind SP1. At 4:45:02 p.m., the AV closed his/her bedroom door. SP1 stopped at a closet and almost immediately, SP2 passed the closet and was about three feet behind SP1. The SPs continued into the common area, and each went into a different part of the facility out of camera range.

About two minutes later, SP2 walked toward the AV’s bedroom, opened the closed bedroom door, and entered. SP2 found the AV with a hoodie tied around his/her neck, which s/he quickly removed. The AV’s face was blue, but s/he recovered and the HCP who assessed him/her determined that the AV did not require additional care.

SP1 said there was a miscommunication, thought that SP2 was the AV’s shadow, did not think that s/he was the AV’s staff shadow, and thought that all staff persons were responsible for supervising the AV when the incident occurred.

SP2 might have verbally instructed SP1 to shadow the AV during the shift, but the video recording showed that the SPs were both with the AV in his/her bedroom, then SP1 walked past SP2 away from the AV’s bedroom while the AV remained in the bedroom without supervision from a staff person. The SPs exited the AV’s bedroom within seconds of each other, and there were no staff persons supervising the AV. The AV then tied a hoodie around his/her neck and his/her face was blue when SP2 located him/her.

After the AV and SP1 were excluded from the ratio counts, there was one staff person for each 2.67 youths when the incident occurred. The facility was in ratio. However, SP1 felt pulled in several directions and thought there were not enough staff persons to meet the needs of the youths.

Given that the AV was not supervised according to the facility’s Suicidal Ideation and Gesture Protocol which was a violation of Minnesota Statutes, section 245A.04, subdivision 14, (b), (1-3), and tied a hoodie around his/her neck causing his/her face to turn blue, there was a preponderance of the evidence that there was a failure to protect the AV from conditions or actions that seriously endanger the AV’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; or 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).

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 Human Services for at least ten years after the date of the final entry in the report.

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2):

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 Staff Management Policy showed that the facility was to provide at least one staff person to three youths within the living unit during awake hours. On August 17, 2024, P2, P3, SP1, and SP2 were responsible for supervising nine youths in the unit of the facility in which the incident occurred. The facility’s Suicidal Ideation and Gesture Protocol showed that when staff persons shadowed youths, they were to be in the same room with the youth or have eyes on the youth. Youths were not permitted to close their bedroom doors unless they were changing clothes.

SP2 said that s/he assigned SP1 to shadow the AV and the facility’s policies showed that staff persons were to supervise youths by keeping eyes on them or being close enough to youths to physically intervene. SP1 thought that SP2 was shadowing the AV on the date of the incident. Video from the facility showed that SP1 and SP2 were both in the hall outside the AV’s bedroom when the AV closed the bedroom door and that SP2 walked past SP1 in the hall, moving away from the AV’s bedroom to a facility common area after the AV closed the bedroom door.

Given that the facility’s Suicidal Ideation and Gesture Protocol instructed staff persons how to supervise youths when they were shadowed, and that the facility was in staffing ratio when the incident occurred, the facility’s responsibility was mitigated.

According to staff ratios, there were enough staff persons to supervise the youths when the incident occurred, but SP1 thought that SP2 was shadowing the AV, and SP2 said that SP1 was assigned to shadow the AV. SP1 felt that his/her attention was being pulled in multiple directions, leaving him/her unable to supervise the AV. Information was consistent that the responsibility for staff shadow was written on a white board in the facility office that was erased at the end of the shift.

Given the aforementioned, that it was unknown whether adequate instructions were given to SP1 to ensure that s/he knew that s/he was shadowing the AV, that the SPs were each in the hall near the AV’s bedroom when the AV closed the bedroom door, and that there was conflicting information regarding who was responsible for shadowing the AV on the date of the incident, the responsibility for the maltreatment was inconclusive.

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but were not followed. The facility retrained its staff persons on staff shadow protocol, and staff persons who were responsible for completing safety checks/staff shadow for the AV were given “corrective action.”

Action Taken by Department of Human Services, Office of Inspector General:

On April 23, 2025, the facility was issued a Correction Order for the violations 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 Human Services.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


state: MN

raw_content:
March 17, 2026                    CERTIFIED MAIL

Michelle Murray, Authorized Agent
Nexus Family Healing Hennepin County Crisis Stabilization Program

505 Highway 169 N, Suite 500

Plymouth, MN 55441-6447

License Number 1126892 (CRF)

ORDER TO PAY A FINE FOR

BACKGROUND STUDY VIOLATION

Dear Michelle Murray:

The Department of Human Services (DHS) is ordering you to pay a fine of $200 for a background study violation. Details of our findings are provided below. Our next steps and your options are also detailed.

Reason for the Fine

DHS is issuing this fine order because you did not comply with the following background study requirement:

Background Study Violation Determined on January 14, 2026:

1. While reviewing critical incident reports, a DHS licensor determined that you did not request a background study for a staff person before they began working in a position allowing direct contact with children.

SP1 began working in a position allowing direct contact with children on December 16, 2025; however, the license holder did not initiate a background study to DHS until the oversight was discovered and brought to their attention by a licensor on January 14, 2026.

The failure to initiate a background study on staff persons before they begin working in a children’s residential facility, allowing direct contact with persons served by the program, is a violation of background study requirements.

Statute Violated: MN Statutes, section 245C.03, subdivision 1, paragraph (a), clause (8),245C.04, subdivision 11, clause (5) and 245C.13, subdivision 2, paragraph (c), clause (6).

Fine: $200 ($200 per violation)

Corrective Action Required: Immediately and on an ongoing basis, you must comply with the background study requirements in Minnesota Statutes, chapter 245C. Upon notification of the background study violation the license holder corrected the violation for SP1.

Billing and Payment of the Fine

DHS will send you an invoice for the $200 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. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

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, you are personally 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.

Your Right to Appeal

You have the right to 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 receive this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

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.lawhelpmn.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

· DHS may impose a $200 fine for each background study violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iv).

· The exception that allows a license holder who self-corrects a background study violation to avoid a fine does not apply when the license holder was cited for the same violation within the past 365 days, under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d)(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)(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.

· 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.

· NetStudy 2.0 is defined by Minnesota Statutes, section 245C.02, subdivision 13e.

Questions

If you have any further questions regarding this matter, you may contact Paula Halvorson, Supervisor, at 651-431-5653.

Sincerely,

Paula Halvorson, Unit Manager

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Notice of Violation


facility_name: Nexus Gerard Family Healing

report_date: January 27, 2026

summary: CORRECTION ORDER

raw_content:
January 27, 2026

Michelle Murray, Authorized Agent

Nexus Gerard Family Healing

505 Highway 169 North, Suite 500

Plymouth, MN 55441

RE:  Report No. 202510172

Nexus Gerard Family Healing

License No. 831080

Dear Michelle Murray:

CORRECTION ORDER

An investigation of Nexus Gerard Family Healing was completed regarding report number 202510172, which alleged violations of Minnesota Statutes chapter 260E and Minnesota Rules chapter 2960. This maltreatment allegation concerned physical abuse. The disposition of the investigation report is maltreatment not determined. Two violations were noted.

VIOLATIONS AND CORRECTION ORDERS

The following violations of state and (or) federal laws and rules were observed. Corrective action for each violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

1.  Citation: Minnesota Statutes 245A.66, subdivision 4, paragraph (a)

Violation: For five of five staff persons whose records were reviewed (S1-S5), the license holder did not provide training annually on the maltreatment of minors reporting requirements and definitions in chapter 260E.

S1-S4 received training on maltreatment of minors in February 2024 and then not again until October 2025. S5 received this training in August 2024 and not again until October 2025.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision.

2.  Citation: Minnesota Rules part 2960.0710, subpart 5

Violation: The license holder did not ensure every physical intervention was documented including the technique used, the time of day, and the name of the staff person and resident involved.

On October 24, 2025, a staff person (S5) escorted a resident back to their living unit after they left down a hallway. The incident was not documented as required.

Corrective Action Ordered: The facility must retrain S5 on the use of restrictive procedures and the documentation of such, and on an ongoing basis, you must maintain compliance as required with this subdivision.

If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to:

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order.

If you have any questions regarding the investigation, contact investigator Lindsay Arth. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Hannah Horsch at 651-431-6270 and Hannah.Horsch@state.mn.us.

Sincerely,

for

Lindsay Arth, Senior Investigator

Office of Inspector General

Licensing Division

651-431-6537

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Correction Order


raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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.”

Report Number: 202510172

Date Issued: January 27, 2026

Name and Address of Facility Investigated:

Nexus Gerard Family Healing
1111 28th Street Northeast
Austin, MN 55912

Disposition: Maltreatment not determined.

License Number and Program Type:

831080-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

Lindsay Arth/Beth Virden
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6537

Suspected Maltreatment Reported:

It was reported that a staff person (SP) grabbed an alleged victim’s (AV) hair, pulled the AV to the floor, and called the AV a “bitch.”

Date of Incident(s): October 24 and 26, 2025

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 18, paragraph (a), and subdivision 23, paragraph (a):

"Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on November 17, 2025; from documentation at the facility; and through eight interviews conducted with the AV, the AV’s family member (FM), the AV’s case managers (CM1 and CM2), a facility staff person (SP), a mental health professional (P1), and supervisory staff persons (P2 and P3).

In February 2025, the AV moved into the facility seeking services and support relating to his/her diagnoses, which included generalized anxiety disorder and oppositional defiant disorder. The facility provided the AV with residential treatment and education. At the time of this investigation, the AV was 14 years old.

The facility was a campus with multiple buildings and living units for youth ages 6 to 18. There were cameras mounted in common areas, hallways, etc., which recorded movement but not audio.

The facility’s Handle with Care policies and procedures stated the following:

· The facility served high-risk and emotionally dysregulated youth, who might display physically aggressive and harmful behaviors toward themselves and others. The use of physical holds might be a necessary intervention to keep youth and staff safe from physical harm.

· Physical hold techniques included a one-person escort, whereby the staff stood behind the youth with their chest close, elbows under elbows, fingertips and wrists pointed straight up, and then staff walked the youth forward or backward.

· “Holding youth in uncomfortable or awkward positions as well as arm twisting, arms held high behind the back, hair pulling, or extensive squeezing of the youth is not acceptable or tolerated. The youth must always be treated respectfully throughout the physical hold procedure.”

The AV provided the following information:

· On at least two occasions in October 2025, the SP “got upset” and “grabbed” the AV’s clothes “kind of violently.” The SP then “dragged” the AV, which also pulled on the AV’s hair; however, the AV did not believe the SP intentionally pulled his/her hair. The SP called the AV a “bitch” and said that the AV’s family did not want him/her, which was why s/he was living at the facility.

· The AV said that the SP “wasn’t physically abusing” him/her and never hit the AV or caused injury, but the AV did not like being touched and told the SP that s/he did not like being touched, yet more than once, the SP did so anyway.

The facility’s camera footage showed two incidents, October 24 and 26, 2025 (respectively), where the AV walked away from his/her living unit towards a set of double doors, which led outside. Both times, the SP followed and grabbed the AV’s sweatshirt at his/her shoulders, shifting the AV off-balance, and then walked behind the AV away from the double doors. The physical contact in each incident was less than ten seconds.

The SP said that twice in October 2025, the AV ran out of the living unit and the SP was the sole staff able to physically respond. The SP believed s/he needed to intervene because of the AV’s history jumping out of windows and running away. Both times, the AV stopped in the hallway and the SP “pinched [the AV’s] sweatshirt” and led him/her back to his/her living unit. The SP did not intentionally touch the AV’s hair, did not drag the AV, did not swear at the AV, and did not tell the AV that his/her family did not want him/her; and the AV did not sustain injuries. The SP said that s/he and the AV used to get along but around September 2025, the SP implemented stricter personal boundaries with youth to be more professional, which the AV did not like. [Note: The SP completed an incident report for the incident on October 26, 2025, but not for the incident on October 24, 2025, which was a violation of Minnesota Rules part 2960.0710, subpart 5, which states that staff must document the use of physical escort and note the technique used, the time of day, and the name of the staff person and resident involved.]

P1-P3 each said that they did not witness incidents of the SP’s conduct, or hear the SP make statements, like those described by the AV and did not have concerns with the SP’s conduct. P1 and P3 each reviewed camera footage and saw the SP redirecting the AV by grabbing his/her sweatshirt and guiding him/her away. Although the way the SP escorted the AV was inconsistent with the facility’s handle with care escort procedures, the AV appeared to be about to run away and so some type of intervention was warranted, and the SP showed “no force” or “dragging” as described by the AV. P1-P3 each said that the AV was not always an accurate reporter of information. The SP had started becoming firmer with maintaining boundaries and rules, which seemed to “upset” the AV and made the AV “target” the SP.

The FM, CM1, and CM2 provided consistent information that the AV might provide accurate information but also might leave out important details or misinterpret events. CM1 said that around the time of the incidents, the AV had gotten in trouble at the facility for having contraband in his/her bedroom. The AV had a history of engaging in behaviors when s/he was held accountable.

Facility documentation stated the SP and P1-P3 received training on the facility’s handle with care policies. P1-P3 and the SP also received training on the Reporting of Maltreatment of Minors Act; however, the training was not provided prior to or within the same month of the subsequent calendar year, which a violation of Minnesota Statutes section 245A.66, subdivision 4, paragraph (a), which states in part that mandated reporters must have annual training on the maltreatment of minors reporting requirements.

Conclusion:

The facility’s camera footage showed that on October 24 and 26, 2025, the AV walked down a hallway toward an exterior door, and the SP followed, grabbed the AV’s sweatshirt, and led the AV back to his/her living unit. Consistent information was provided by P1-P3 and the SP that the AV had a history of running away so an intervention was necessary to protect the AV.

Although the AV stated that the SP grabbed the AV’s clothes “violently,” “dragged” the AV, pulled on the AV’s hair, and made statements such as calling the AV a “bitch” and stating the AV’s family did not want him/her, given that the SP denied the allegation which was supported by the camera footage which showed that the SP did not engage in the actions as described by the AV and there was no audio on the camera footage; that the SP’s actions of grabbing the AV’s sweatshirt and then walking behind the AV did not cause injury to the AV and/or would not reasonably be expected to cause injury; that P1-P3 did not have concerns regarding the SP, there was not a preponderance of the evidence that the SP dragged the AV, pulled the AV’s hair, and/or made inappropriate statements to the AV.

It was not determined that physical abuse occurred ("physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury).

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed as the staff did not use an approved physical restraint technique when escorting the AV back to the unit. The facility retrained staff on the handle with care policies and procedures.

Action Taken by Department of Human Services, Office of Inspector General:

On January 27, 2026, the facility was issued a Correction Order for the violations 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 Human Services.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/

doc_type: Maltreatment Finding


report_date: November 4, 2025

raw_content:
November 4, 2025

Michelle Murray, Authorized Agent

Nexus Gerard Family Healing

505 Highway 169 North

Plymouth MN, 55441

License Number: 831080 (CRF)

Report Numbers: 202407792, 202502585, and 202506518

CORRECTION ORDER

Dear Michelle Murray:

On September 15 through 18, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Nexus Gerard Family Healing located at 1111 28th Street Northeast, Austin, Minnesota, 55912. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and residential mental health treatment under Minnesota Rules, 2960.0580 through 2960.0700, restrictive techniques standards under Minnesota Rules, part 2960.0710, with a residential program certification as a qualified residential treatment program under Minnesota Statutes, section 245A.25. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

DHS determined that your program failed to follow licensing rules and statutes, as described below.

Physical Plant

1. Violation: The license holder’s physical environment did not provide for the comfort, privacy, and dignity of residents. Units Chateau and Cherbourg did not have window coverings on windows in the residents’ rooms.

Rule Violated: Minnesota Rules, part 2960.0110, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the physical plant.

Practices

2. Violation: The license holder did not have documentation to demonstrate that an internal review was completed for alleged maltreatment of a minor for incident occurring on July 18, 2025.

Statute Violated: Minnesota Statutes, section 245A.66.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of maltreatment reporting. Within 30 days receipt of order, submit documentation of the internal review completed for the incident occurring on July 18, 2025, that demonstrates compliance with all requirements.

3. Violation: The license holder did not have documentation that they conducted an annual evaluation of the program’s strengths and weaknesses according to performance indicators identified in Minnesota Rules, part 2960.0060, subpart 3, item A, for calendar years of 2023 and 2024.

Rule Violated: Minnesota Rules, part 2960.0060, subpart 3.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the annual evaluation of the program’s strengths and weaknesses meets all requirements.

4. Violation: The license holder’s provision of weekly clinical supervision did not meet requirements in two of two weeks reviewed. Clinical supervision documentation indicated a mental health professional did not provide clinical supervision to staff providing program services to a resident for the following:

a. For the weeks of July 2 through 8 and July 3 through 9, 2025, 27 staff members didn’t receive clinical supervision; and

b. For the weeks of September 3 through 9 and September 4 through 10, 2025, 14 staff members didn’t receive clinical supervision.

Rule Violated: Minnesota Rules, part 2960.0630, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision meets all applicable requirements. Within 30 days receipt of order, submit a plan that outlines how the program will maintain compliance with requirements.

Personnel

5. Violation: One of fifteen personnel files reviewed for requirements governing background studies did not meet requirements. The license holder did not notify the commissioner or initiate a new background study for a staff person who underwent a legal name change (personnel file numbered 16).

Statute Violated: Minnesota Statutes, section 245C.04, subdivision 7.

Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance has been achieved and how compliance will be maintained in the future.

6. Violation: One personnel file reviewed for staff qualifications did not meet requirements. The license holder did not have documentation showing that the staff’s professional licensure was current (personnel file numbered 15).

Rule Violated: Minnesota Rules, part 2960.0150, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation in personnel files meets all applicable requirements.

7. Violation: Eight of eight personnel files reviewed for orientation training did not meet requirements in the following ways:

a. The license holder did not have documentation to demonstrate that staff members completed the following orientation trainings before having unsupervised direct contact with residents:

i. Emergency procedures (personnel files numbered 3, 4, 5, 7, and 11);

ii. Maltreatment of minors reporting requirements (personnel files numbered 3 and 7);

iii. Cultural diversity and gender sensitivity (personnel files numbered 3, 4, 5, 7, and 11);

iv. General and special needs, including disability needs, of residents and families served (personnel files numbered 2, 3, 4, 5, 7, 11, 12, and 13);

v. Data practices regulations and issues (personnel file numbered 11);

vi. Concepts of trauma-informed care and how to provide services to each youth according to those concepts (personnel file numbered 7); and

vii. Impacts of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences (personnel files numbered 3, 4, 5, 7, and 13)

b. Medication assistance training provided by the registered nurse was not placed in the unlicensed staff person’s personnel file (personnel files numbered 4 and 11);

c. The license holder did not have documentation to demonstrate that staff received an orientation to vulnerable adults maltreatment reporting requirements and definitions (personnel files number 3 and 7);

d. The license holder did not have documentation to demonstrate that staff members completed training on the following items during the first 45 calendar days of employment, and before assuming sole responsibility for the care of residents:

i. Residents’ rights (personnel files numbered 3, 4, 5, 7, 11, and 12); and

ii. Problems and needs of residents with severe emotional disturbance and their families (personnel files numbered 3, 4, 7, 11, and 12)

e. The license holder did not have documentation that they provided training to program staff related to their duties in implementing the program's policies and procedures (personnel file numbered 13).

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph b, 245A.25, subdivision 3, paragraph b, and 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0080, subpart 11, item D, subitem 5, 2960.0100, subpart 3, item A, and 2960.0650, subpart 1, items B and G.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days receipt of order, submit documentation of a newly oriented staff member that demonstrates compliance with all orientation requirements.

8. Violation: Seven of seven personnel files reviewed for ongoing training did not meet requirements in the following ways:

a. The license holder’s documentation did not demonstrate that the staff person received training annually for these topics:

i. Vulnerable adults maltreatment reporting requirements and definitions in the following calendar years:

1. 2023 (personnel files numbered 8 through 10 and 15); and

2. 2025 (personnel files numbered 6, 8, 9, 14 and 15)

ii. The license holder’s Program Abuse Prevention Plan in the following calendar years:

1. 2023 (personnel files numbered 10 and 15);

2. 2024 (personnel files numbered 6, 9, and 14); and

3. 2025 (personnel files numbered 8, 10, and 15)

iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services in the following calendar years:

1. 2023 (personnel files numbered 8, 9, 10, and 15); and

2. 2025 (personnel files numbered 6, 8, 9, 11, 14, and 15)

iv. Maltreatment of minors reporting requirements in the following calendar years:

1. 2023 (personnel files numbered 8, 9, 10, and 15); and

2. 2025 (personnel files numbered 6, 8, 9, 11, 14, and 15)

v. The impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma in the calendar year 2025 (personnel files numbered 9, 14, and 15)

b. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 4 through 11, 14 and 15).

Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 3, paragraph h, 245A.65, subdivision 3, 245A.66, subdivision 4, Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subpart 3, item A.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements.

Residents

9. Violation: Two of seven resident files reviewed for admission procedures did not meet requirements. The inventory of the resident’s personal property was not signed by the resident or two staff members if the resident refused to sign (resident files numbered 1 and 5).

Rule Violated: Minnesota Rules, part 2960.0070, subpart 4.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meet all applicable requirements.

10. Violation: One resident file reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. The IAPP did not contain an individualized assessment of the person’s susceptibility to abuse by other vulnerable adults (resident file numbered 4).

Statute Violated: Minnesota Statutes, section 245A.65. subdivision 2, paragraph b.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that IAPPs meet all applicable requirements.

11. Violation: Seven of seven resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways:

a. The health screening did not occur within 24 hours of admission (resident file numbered 7) and did not note the resident’s vulnerability to abuse (resident files numbered 1 through 5, 7, and 8);

b. The resident was not screened for vulnerabilities to abuse and sexually abusive behaviors using an instrument approved by the commissioner. The tool used did not include the following (resident files numbered 1 through 5, 7, and 8):

i. If the child has a history of vulnerability such as being teased, picked on, or other indications of potential safety issues with other residents;

ii. If the child has a history of boundary violations; or

iii. If the child’s history indicates the need for special precautions or particular staffing patterns in the facility.

c. The gender-based needs screening was not completed (resident files numbered 1, 2, 5, 7, and 8);

d. The screenings did not include documented inquiries and the results of the inquiries regarding the degree to which the resident's family desires to be involved during the resident's stay at the facility (resident files numbered 3 and 7); and

e. The license holder did not complete a screen for trauma by completing a trauma-specific screening tool with each youth upon the youth’s admission. The screening completed by the program was completed after admission (resident files numbered 1 through 4, 7, and 8).

Statute and Rule Violated: Minnesota Statutes, section 245A.24, subdivision 3, paragraph c and Minnesota Rules, part 2960.0070, subpart 5, items A, B, C, and D.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission screenings meet all applicable requirements. Within 30 days receipt of order, submit documentation of a newly admitted resident that demonstrates compliance with all admission screening requirements.

12. Violation: Two of six resident files reviewed for requirements governing program services did not meet requirements. There was not documentation to demonstrate that the license holder contacted and facilitated outreach to the residents’ siblings (resident files numbered 3 and 4).

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph g.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program services meet all applicable requirements.

13. Violation: Seven of seven resident files reviewed for requirements governing treatment plans did meet requirements in the following ways:

a. There was not documentation that the license holder assigned the resident to a designated staff person to ensure regular face-to-face contact and to monitor and assist the resident to implement the treatment plan (resident file numbered 2 and 3);

b. The treatment plan was not completed within ten days of admission (resident files numbered 1 through 5, 7, and 8);

c. The treatment plan did not include a schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 5, 7, and 8);

d. Psychotropic medication was not included in the treatment plan for a resident prescribed a psychotropic medication (resident file numbered 2);

e. A mental health professional did not sign the treatment plan (resident file numbered 1); and

f. The treatment plan did not include how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youth’s siblings (resident file numbered 3).

Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph h, Minnesota Rules, parts 2960.0180, subpart 2, item B, 2960.0600, item A, 2960.0620, subpart 1, item A, and 2960.0630, subpart 3, item B.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days receipt of order, submit a treatment plan that demonstrates compliance with all requirements.

14. Violation: Five of seven resident files reviewed for requirements governing health care did not meet requirements. The license holder did not have documentation to demonstrate if all scheduled medications were administered on the following dates:

a. March 19 and 22, 2025 (resident file numbered 2);

b. March 26, May 7, 2025, and October 5, 2024 (resident file numbered 3);

c. October 7, 2024, and January 13 and 16, 2025 (resident file numbered 4);

d. August 19, 2025 (resident file numbered 7); and

e. December 24, 2024 (resident file numbered 8).

Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item E.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must unsure that the provision of health care services meets all requirements.

15. Violation: Seven of seven resident files reviewed for requirements governing psychotropic medications did not meet requirements in the following ways:

a. Documentation did not demonstrate that the license holder checked for side effects at least weekly for the first six weeks after a resident began taking a new psychotropic medication and at least quarterly thereafter (resident files numbered 1, 2, 4, 5, and 7);

b. Documentation did not demonstrate that the license holder monitored for tardive dyskinesia at least every three months for a resident prescribed an antipsychotic medication (resident files numbered 3 and 5); and

c. The license holder reported they are not conducting monthly and quarterly psychotropic medication reviews to the requirements in Minnesota Rules, part 2960.0620, subpart 5, and there was no documentation in the resident file (resident files numbered 1 through 5, 7, and 8).

Rule Violated: Minnesota Rules, parts 2960.0620, subparts 2 and 5.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the use of psychotropic medications meets all applicable requirements. Within 30 days receipt of order, submit documentation of one resident’s monthly psychotropic medication reviews that demonstrates compliance with all requirements.

16. Violation: Seven of seven resident files reviewed for requirements governing informed consent did not meet requirements (resident files numbered 1 through 5, 7, and 8). Informed consent documentation did not include the following required components:

a. The level to which the medication is to change the symptoms and behavior and an indication of the method used to determine the expected benefits; and

b. The pharmacological and nonpharmacological treatment options available and the course of the condition with and without treatment options.

Rule Violated: Minnesota Rules, chapter 2960.0620, subpart 7, items A and C.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that informed consents meet all applicable requirements. Within 30 days receipt of order, submit documentation of one resident’s informed consents that demonstrates compliance with all requirements.

17. Violation: One of three resident files reviewed for requirements governing the use of time out procedures did not meet requirements. Documentation reviewed in milieu notes detailed an instance on July 19, 2025, where time-out was used, but the documentation required following the use of a time-out was not completed (resident file numbered 7).

Rule Violated: Minnesota Rules, chapter 2960.0080, subpart 5, item D.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that time out procedures meet all applicable requirements.

18. Violation: Five of five resident files reviewed for requirements governing the use of restrictive procedures did not meet requirements in the following ways:

a. Documentation did not demonstrate that the staff person who implemented the restrictive procedure documented its use immediately after the incident concluded on restrictive procedures that occurred on the following dates:

i. August 29, 2025 (resident file numbered 1);

ii. September 13 and 15, 2024 (resident file numbered 3);

iii. January 12, 2025 (resident file numbered 4);

iv. April 6 and 12 and August 17, 2025 (resident file numbered 5); and

v. and July 18, 24, 25, and 26, 2025 (resident file numbered 7).

b. Through reviewing video footage and conducting staff interviews as part of a licensing investigation, it was determined that a restrictive procedure that occurred on July 18, 2025, did not meet requirements in the following ways (resident file numbered 7):

i. The physical holding technique was not included in the license holder’s approved restrictive procedures plan. Video footage of the physical holding showed a staff person’s knee and shin placed across the resident’s stomach and chest;

ii. The resident was not treated respectfully throughout the procedure. Video footage of the physical holding showed a staff person stepping over the resident and grazing the resident’s face with their foot;

iii. An administrative review was completed following the use of physical holding, but it did not identify that the rule standards governing the use of restrictive procedures were not met;

iv. Information obtained during investigative interviews indicated that a staff person involved with the physical hold, who did not treat the resident respectfully, required additional training. There was no documentation to demonstrate any additional training was completed.

Rule Violated: Minnesota Rules, part 2960.0710, subparts 6, items J and K and 10, item C.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures meet all applicable requirements. Within 30 days receipt of order, submit documentation that personnel file numbered 7 received additional training on the use of restrictive procedures.

19. Violation: One of six resident files reviewed for requirements governing discharge procedures did not meet requirements. The resident file did not contain a signed receipt of personal property (resident file numbered 5).

Rule Violated: Minnesota Rules, part 2960.0090, subpart 3.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meet all applicable requirements.

20. Violation: Four of four resident files reviewed for requirements governing transition services plans did not meet requirements. There was not documentation to demonstrate that a copy of the plan was given to the resident upon discharge (resident files numbered 2, 3, 4, and 8).

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A.

Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plans meet all applicable requirements.

21. Violation: Three of four resident files reviewed for requirements governing discharge documentation did not meet requirements. The license holder did not have documentation of the extent to which the resident's stay in the facility met the objectives identified in the resident's treatment plan (resident files numbered 2 through 4).

Rule Violated: Minnesota Rules, sections 2960.0140, subpart 2, and 2960.0190, subpart 2.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge documentation meets all applicable requirements.

Written Response Required

If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07.

Submissions required as part of the corrective action ordered must be sent to your licensor by email at Hannah.Horsch@state.mn.gov or by mail:

Commissioner, Department of Human Services

ATTN: Hannah Horsch

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violations. Your request must:

· Be in writing

· List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to:

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General, Legal Counsel’s Office - Licensing

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2.

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6270 or at Hannah.Horsch@state.mn.us.

Sincerely,

Hannah Horsch, Licensor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/


report_date: September 18, 2025

raw_content:
MALTREATMENT INVESTIGATION MEMORANDUM
Office of Inspector General, Licensing Division
Public Information

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.”

Report Number: 202407637

Date Issued: September 18, 2025

Name and Address of Facility Investigated:

Nexus Gerard Family Healing
1111 28th St NE

Austin, MN 55912

Disposition: Maltreatment determined as to physical abuse and neglect of an alleged victim by a staff person.

License Number and Program Type:

831080-CRF (Children’s Residential Facility)

Investigator(s):

Lindsay Arth/Jamie Randall
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
lindsay.arth@state.mn.us

651-431-6537

Suspected Maltreatment Reported:

It was reported that a staff person (SP) squeezed an alleged victim (AV) around his/her neck. It was also reported that the SP dragged the AV out of bed by his/her ankles and the AV sustained a bruise to his/her leg.

Date of Incident(s): September 2, 2024

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); subdivision 18, paragraph (a); and subdivision 23, paragraph (a):

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.

"Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 13, 2024; from documentation at the facility; and through eight interviews conducted with a facility supervisory staff person (P1), four staff persons (P2, P3, P4, and the SP), the AV, the AV’s social worker (SW), and the AV’s family member (FM).

The AV was 13 years old and diagnosed with attention-deficit/hyperactivity disorder, persistent depressive disorder, conduct disorder, and disinhibited social engagement disorder. The AV liked to play volleyball, basketball, and spend time with his/her peers. The AV was working on “developing a skillset to reduce episodes of physical and emotional dysregulation and aggression.” The AV’s plans stated that if the AV “became a safety risk to [him/herself] and/or others, a physical holdings procedure may need to be enacted.”

The facility was a residential mental health treatment facility that assisted youth ages six to eighteen years old. The AV resided in a dorm that consisted of a programming room and six bedrooms. The AV’s bedroom had two sets of bunk beds that accommodated up to four residents. The AV had a top bunk. Outside of the AV’s bedroom was a small hallway that led to other bedrooms and programming area. The facility had cameras in the main areas but none inside the bedrooms. However, part of the AV’s bedroom, including part of the AV’s bed, was visible from one of the camera views.

The Therapeutic and Restrictive Procedures said that staff persons were to “ensure that the safety, rights, and dignity of the youth that we serve are maintained.” Staff persons were required to complete a course and demonstrate competency on approved holds. The facility used “Handle with Care” which stressed the use of verbal de-escalation techniques and then physical holds only as a last resort when “less invasive interventions have been attempted and proven to be unsuccessful.” Physical holds were only to be implemented if “the safety of the youth and others if imminent danger is present by means of physical aggression” or for “the prevention of self-harm/self-destructive behaviors that put the youth or others in imminent danger.” There were multiple variations of holds but all utilized “Primary Restraint Technique” (PRT). PRT was a “skeletal lock position in which the staff member’s chest is in close, elbows under elbows, fingertips and, more importantly, wrists are pointed straight up.”

Consistent information was provided that on September 2, 2024, P2, P3, and the SP worked in the AV’s dorm.

The AV and the Workplace Investigation provided the following information:

· On September 2, 2024, in the morning, the AV was refusing to get out of bed which was the top bunk. The dorm was in a “slow down” because the youth in the dorm were not “behaving.” This meant that there were no “fun” activities, and the AV did not want to get out of bed.

· At about 8:10 a.m., the SP and P2 went into the AV’s room. The SP then grabbed the AV’s left leg and P2 grabbed the AV’s arms and pulled the AV to the floor. When the SP and P2 pulled the AV out of his/her bed, the AV’s leg hit the ladder of the bunk bed. The AV then accidently hit the SP in the stomach and the SP put his/her arms around the AV’s neck and the AV fell to the floor. The AV could not breathe and tapped the SP on the arm. The SP released his/her arms from the AV’s neck. The AV counted and the SP had his/her arms around the AV’s neck for 30 seconds. The AV went into the hallway just outside of his/her bedroom to “get away” from the situation. P2 followed the AV into the hallway and the AV pushed P2. P2 then put the AV into a hold.

· The AV showed his/her left leg to this investigator and said that there was a bruise (Note: This investigator did not see any injuries). There were no injuries to his/her neck from the incident.

· The AV said that the SP and P2 should have tried talking with him/her instead of dragging him/her out of bed.

P2 and the Workplace Investigation provided the following information:

· On September 2, 2024, P2 worked in the AV’s dorm starting at 7 a.m. After breakfast, the AV was in his/her room and refused to get out of bed. P3 was trying to encourage the AV to get out of bed for an activity but the AV continued to refuse to get out of bed. P3 left the AV’s room to supervise the other youth in the programming area.

· In between 8:15 and 8:45 a.m., P2 was supervising the other youth in the programming area. The SP, who was returning to the dorm after using the restroom, told P2 that s/he was going to “drag” the AV out of bed if the AV was still refusing to get out of bed. The SP started to walk toward the AV’s room and P2 followed because s/he wanted to see if the SP would be successful in getting the AV out of bed.

· When the SP and P2 arrived in the AV’s room, the SP verbally encouraged the AV to get out of bed. The AV refused and the SP then grabbed one of the AV’s ankles. P2 was not sure if the SP grabbed the AV’s right or left ankle. The AV said, “Ow,” when the SP grabbed his/her ankle. When the SP started to pull on one of the AV’s ankles to get the AV out of bed, P2 held the AV’s head and arm with an “open palm” and leaned the AV “forward” because s/he was worried the AV would hit his/her head and/or fall to the floor. When the AV was “halfway down” off the bunk bed, the SP let go of the AV’s ankle and the AV landed with his/her feet on the floor. The AV then attempted to punch the SP in the stomach so P2 attempted a hold. During this, the SP “tackled” the AV and used his/her left arm and wrapped it around the AV’s neck in a “chokehold.” The SP and the AV both ended up on their knees. P2’s right arm was in between the SP and the AV from P2’s attempted hold on the AV. The AV said that s/he “couldn’t breathe,” and the SP released his/her arm from around the AV’s neck.

· The AV went into the short hallway outside his/her room and started to scream and yell. P3 came to the hallway and was pushed onto the floor by the AV. The AV then started to hit P2 so P2 put the AV into a hold until s/he calmed. After P2 ended the hold on the AV, P2 went to supervise the other youth in the dorm while the AV stayed in the hallway outside his/her room for “awhile.” The AV was able to “turn [his/her] day around” after the incident and followed “expectations.”

· P2 did not see any injuries or bruises on the AV. P2 was “pretty sure” that the AV mentioned a bruise on his/her leg but P2 did not see the bruise.

· In general, the SP would “brush off” comments from others regarding the care of the youth. P2 felt that the SP would not have listened to him/her if s/he would have objected to pulling the AV out of bed. P2 said that holding someone around their neck was not an approved hold and that the SP should have left the AV in bed because the AV was not in any danger of hurting him/herself or others.

P1 and the Workplace Investigation provided the following information:

· On September 2, 2024, between 5:30 and 6 p.m., a supervisory staff person (P5) told P1 that P2 told him/her that between 8 and 9 a.m. that morning, the SP wrapped his/her arms around the AV’s neck from behind. P2 told P5 that s/he was “afraid” to say something earlier in the day while the SP was still on shift. P5 told P1 that the AV was “doing okay” and there were no signs of injury to the AV’s neck. However, P2 saw a bruise on the AV’s left leg. The AV was not seen by medical personnel as the incident happened in the morning and the AV was “doing okay.”

· P1 reviewed camera footage from September 2, 2024, that showed the hallway and the doorway of the AV’s dorm room. The SP and P2 enter the AV’s dorm room at 8:22 a.m. and the SP, P2, and the AV exit the room around 40 seconds later.

· P1 said that if a youth was refusing programming/activity, the staff person should provide encouragement for the youth to “get back on path” but should “wait them out” and make sure the youth understood the consequences of doing or not doing a planned activity.

· On September 3, 2025, the AV was brought by P1 to meet with P4 to discuss the situation. The AV did not give “a lot if info” so P1 met with the AV. P1 encouraged the AV to discuss the incident with P4. P1 thought that the AV’s history of not always providing accurate information caused the AV to be hesitant about discussing the incident.

· P1 previously brought up concerns to the SP regarding his/her behavior at the facility. This included that the SP had been more “snippy” when interacting with the youths and had a “negative attitude” when coming into work.

· P1 was told by another supervisory staff person who spoke with the SP, that the SP denied choking the AV but admitted to “bear hugging” the AV, which P1 said would still not be “considered a handle with care hold.”

P3 and the Workplace Investigation provided the following information:

· On September 2, 2024, before 8 a.m., the AV completed personal cares and then returned to his/her bed and was refusing to get out of bed. Around 8:15 a.m., P3 tried encouraging the AV to get out of bed but the AV refused. The SP then went into the AV’s room and told the AV that if the AV did not get out of bed that s/he was going to “pull” or “drag” the AV out of bed.

· The SP went to use the restroom and P3 left the AV’s room to supervise the other youth in the programming area. Around 8:30 a.m., when the SP returned, P2 followed the SP into the AV’s room. P3 heard the AV screaming and crying “get off me” and “get your hands off of my neck.” The AV stood in the doorway of his/her dorm and yelled that the SP had “no right to choke [him/her].” The AV then “went after” the SP so P2 tried to put the AV in a hold in the hallway just outside the AV’s dorm. P3 tried to assist with the hold but while doing so, P2 and the AV went to the floor. P2 and the AV were rolling on the floor and P3 got bumped into and fell to the ground when s/he tried to assist with the hold. The AV got his/her hair into his/her mouth during the hold and asked for his/her hair to be removed from his/her mouth. P3 went to assist the AV, and the SP yelled that P3 should not help the AV as getting hair in the AV’s mouth was a “natural consequence” for his/her actions. The SP asked the AV why s/he hit him/her and told the AV that s/he would not have “put my hands on you if you didn’t hit me.”

· P2 told P3 that the SP told him/her that they were going to “pull” the AV out of bed. P2 also told P3 when the SP pulled the AV out of bed, P2 caught the AV and prevented them from falling to the floor.

· After the incident, P3 noticed a few scratches on the AV’s neck. P3 did not see the SP put his/her hands on the AV’s neck but did hear the AV yell, “Why did you put your hands on my neck?”

· P3 said the AV should have been left in bed if s/he was refusing to get up. If the AV was choosing to be “off path,” staff persons should not force the AV to do anything.

P4 provided the following information:

· On an unknown date, P4 received an email on a Sunday that asked him/her to discuss a situation with the AV when s/he arrived to the facility the following morning.

· On September 3, 2025, the AV recalled the incident to P4. The AV was on the top bunk and was refusing to get out of bed because s/he “didn’t feel like it.” The SP grabbed his/her ankles and P2 grabbed his/her arms and pulled him/her down off the bed. The AV landed on the floor and “swung” his/her arm to push past the SP and accidently hit the SP in the stomach. The SP got behind the AV and put his/her arms around the AV’s neck. The AV said that s/he could not breathe and could not talk so s/he started to “tap” the SP on the arm. The SP released the hold around the AV’s neck and put the AV’s arms into a hold for around 30 seconds.

· The AV showed P4 a bruise on the outside of his/her left leg. The bruise was about three to five inches long in an oval shape and was “brownish yellow” in color. P4 did not know if the AV had this bruise prior to the incident. P4 did not take a photo of the bruise and was not aware of anyone else taking a photo of the bruise. P4 did not see any injuries on the AV’s neck and the AV said, “No,” when P4 asked if s/he had any injuries to his/her neck.

· P4 said that staff persons were to provide “encouragement” to the youth but if they choose to be “off path” to “pause the routine.” A youth should never be dragged out of bed if they were refusing to get out of bed. A staff person should never put their hands on a youth’s neck during a hold.

The FM said that the AV had a history of providing false information while living with the FM and had recently accused staff persons of not assisting the AV when the AV was “assaulted” by another youth at the facility. Camera footage of the “assault” incident was not consistent with the information the AV provided.

The SW would visit the AV in the facility once per month and would talk on the phone a “couple time” a month. The SW said that the AV had a history of not always providing accurate information and would use “manipulation” to get his/her way.

The SP provided the following information:

· On September 2, 2024, the SP was scheduled to start at 6:50 a.m. When the SP arrived for his/her shift, s/he was informed by P5 that the dorm was to be in a “slow down.” This included that the previous night, there were multiple incident reports including one with the AV. Chairs in the dorm were turned to face the wall, so the youths “knew” that the dorm was in a “slow down.” The AV was “upset” by this and questioned why s/he needed to be a part of the “slow down.” The SP explained to the AV that his/her actions from the previous night were a part of the reasoning. The AV “got mad” and refused to get out of bed. P2 and P3 tried verbal encouragement with the AV but were unsuccessful.

· At 8:23 a.m., the SP and P2 entered the AV’s dorm room. The SP tried verbal encouragement to get the AV out of bed but was also unsuccessful. The AV was in the top bunk and the SP initially stepped on the ladder to pull the AV out of bed but decided to stay on the floor. The SP went to grab both of the AV’s legs but only grabbed one of his/her ankles as the AV started to kick at the SP. P2 then grabbed the AV’s “upper body” and the SP and P2 pulled the AV out of bed and the AV “tumbled” onto the floor. The AV immediately got up and attempted to punch the SP in the stomach. The SP moved to the side and then “hugged” the AV. The SP and the AV fell to the floor and then both got up off the floor. The AV separated from the SP’s hold and went into the hallway, slamming the door on the way out. P2 put the AV into a hold and the SP called P3 for help. When P3 got into the hallway where P2 was holding the AV, the SP “stepped back” and then filled out an incident report for the AV being put into a hold.

· The SP and P2 “debriefed” after the incident. The SP and P2 agreed that the AV should not have been pulled out of bed. P2 mentioned that while the SP and the AV were on the ground, the AV said that s/he “couldn’t breathe.” The SP thought the AV’s “ginormous” sweatshirt could have gotten into a “weird” position while trying to hold the AV and maybe that was why the AV said that s/he could not breathe. The SP’s hands were “nowhere near” the AV’s neck. The SP said that s/he did not “intentionally” hurt the AV and in his/her witness statement for the Workplace Investigation, wrote that s/he “did not choke [the AV].”

· Following the incident, the AV said his/her arms “hurt.” No other injuries to the AV were noted. The SP was not aware of a bruise on the AV’s leg. However, the AV was put in multiple holds “every day” and any one of those could have caused the bruise on the AV’s leg.

· A “few hours” after the AV was pulled out of bed by the SP and P2, the SP asked the AV if s/he wanted to go out for lunch and the AV said, “Yeah.” The SP and the AV got lunch and came back to the facility. The SP and the AV “chilled” for 10 to 15 minutes “off unit.” The AV “complained” about how s/he did not get along with the other youths but otherwise “seemed fine” and did not bring up the “hold from the morning.”

· The SP said the AV could have stayed in bed and the SP did not think of that “until after.” If the SP allowed the AV to remain in bed, the AV would have eventually left his/her bed, stopped refusing, or gone to the bathroom.

Facility records showed that P1-P4 and the SP were all trained on the AV’s plans, the Reporting of Maltreatment of Minors, and the Therapeutic and Restrictive Procedures policy.

Conclusion:

A. Maltreatment:

Information was consistent that on the morning of September 2, 2024, the AV was refusing to get out of bed and verbal attempts by P3 to get the AV out of bed were unsuccessful. At 8:22 a.m., the SP went into the AV’s room and P2 followed. After attempting to verbally redirect the AV to get out of bed and the AV’s refusal, the SP grabbed one of the AV’s ankles and started to pull the AV from the top bunk. P2 stated that when the SP started to pull the AV out of bed, P2 held the AV by the head and arm to help protect the AV from injury and falling to the floor. While being pulled out of bed, the AV’s leg hit the ladder of the bunk bed. When the AV got to the floor, the AV’s arm hit the SP in the stomach. P2 attempted a hold on the AV but the SP put the AV in a hold with either one or both of his/her arms around the AV’s neck. This hold pinned P2’s arm in between the AV and the SP. The AV said that s/he “couldn’t breathe” and the SP released the hold.

Although the SP denied putting his/her arm around the AV’s neck, given that P2 and the AV each stated the SP put his/her arm around the AV’s neck and P3 heard the AV say to “get your hands off my neck,” it was determined that the SP had his/her arm around the AV’s neck. In addition, information was consistent that the SP initiated pulling the AV out of the top bunk which caused the AV to hit his/her leg on the ladder and fall to the floor when the SP should have used verbal redirection and not done so. Given this, there was a preponderance of the evidence that the SP’s actions were not accidental and represented threatened injury and that the SP failed to protect the AV and supply the AV with care required for the AV’s physical or mental health.

It was determined that physical abuse and neglect occurred ("Physical abuse" means any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child's care on a child other than by accidental means. "Threatened injury" means a statement, overt act, condition, or status that represents a substantial risk of physical or sexual abuse or mental injury; 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), clauses (1) and (2):

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.

While P2 did hold the AV’s head and arm when s/he was pulled out of bed, P2 actions were a response to when s/he saw the SP start to pull the AV out of bed and held the AV’s head and arm to protect the AV from falling to the floor, therefore P2’s responsibility is mitigated.

The SP was trained on the AV’s plans, the Reporting of Maltreatment of Minors, and the Therapeutic and Restrictive Procedures policy. The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services.

Minnesota Statutes, section 245C.02, subdivision 16, states:

“Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment.

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 physical abuse and neglect for which the SP was responsible did not meet statutory criteria to be determined recurring because it was a single incident or serious because it was not determined how or when the AV sustained a bruise on his/her leg.

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 Human Services 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 procedure were adequate but not followed, including because staff persons did not “engage” in the appropriate type of restraint based on their training. The facility provided additional training around the “necessity to engage in appropriate restraint techniques” according to the “trained models.” The SP no longer worked at the facility.

Action Taken by Department of Human Services, Office of Inspector General:

The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is 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 Human Services.

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/