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: 202309898

Date Issued: April 9, 2025

Name and Address of Facility Investigated:

PrairieCare Residential Services
12915 63rd Ave N.
Maple Grove, MN 55369

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

License Number and Program Type:

1082863-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242

gessner.rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that a staff person (SP) and an alleged victim (AV) got into an altercation where the AV and the SP grabbed each other by the hair, and the SP put the AV in a choke hold.

Date of Incident(s): November 23, 2023

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 December 22, 2023; from documentation at the facility; and through four interviews conducted with two facility staff persons (P1 and P2), the SP, and the AV.

The facility was a residential mental health treatment facility that served youth. The facility was located in a mixed office and retail area.

The AV was diagnosed with disruptive mood dysregulation disorder. According to the AV’s progress notes, the AV liked to take brief walks or do relaxation exercises.

The facility’s Residential Restrictive Procedures Plan showed that staff persons were to use the least restrictive, reasonably reliable measures needed to manage resident behavior and needs and not used as means of coercion, discipline, retaliation, or in any other punitive manner. The facility’s Approved Restraint Techniques policy listed the approved methods of restraint for the facility and how they should be implemented, such as a standing restraint technique where a resident was retrained by a staff person from behind or a standing to settle position technique that started out like a standing restraint but lowered the resident to a sitting position. Neither of these techniques allow for the use of a choke hold, head lock, or hitting to restrain a resident.

Video footage of the incident on November 23, 2023, which did not have audio, provided the following information:

· The timestamp showed that at 2:26 p.m., the AV entered a milieu room where other residents were gathered just after and sat down at a table. A moment later the AV approached an area where two other residents were sitting on bean bag chairs, in front of a TV either playing video games or watching TV and grabbed a video game controller located by one of the residents.

· The SP approached the AV at 2:27 p.m., they exchanged words and the AV backed away toward two other bean bag chairs that were up against a nearby wall. The SP attempted to take the controller away but the AV refused to let it go. Another staff person (P1) approached to assist. The SP struggled with the AV and pushed the AV over one of the bean bag chairs. The AV got up and approached the SP, they exchanged words and the AV then lunged toward the SP.

· In the struggle, the AV and the SP spun around, the AV and SP went down on their knees but the AV quickly got up and went after the SP again. P1 pulled the AV away but the SP was still holding on to the AV’s hoodie and the AV grabbed the SP’s hair. The SP did not disengage from the incident or attempt to help P1.

· While P1 was still trying to restrain the AV from behind, the SP stood up punched the AV in the back of the head, and the AV and the SP traded swings with each other. A third staff person attempted to assist to separate the AV and the SP and bring the altercation to an end. However, the SP continued to throw punches at the AV even as the AV went down to the floor in the attempt by P1 and the other staff person to restrain the AV.

· After momentarily being separated, both the AV and the SP continued throwing punches at each other and resumed fighting until the SP put the AV into a headlock, not a choke hold. The two were separated by P1 at 2:28:11 p.m. on the video time stamp.

· P2 arrived after the SP and the AV had been separated. The incident lasted just over one minute.

The AV provided the following information:

· The AV stated that s/he took a video game controller, and the SP wanted it back because the AV was not supposed to be playing video games at that time. The AV turned away from the SP and the SP bear hugged and pushed the AV to the floor. The AV got up and approached he SP and said, “What the hell!” The SP said, “Do something.” So, the AV did.

· Other staff persons tried to hold the AV back to de-escalate the situation, the AV was not hurt by their efforts. The AV recalled that s/he and the SP threw punches at one another, but that the AV threw the first punch. The AV stated that s/he did not want to get the SP in trouble.

· The AV did not recall using the “N” word toward the SP but liked to “push people’s buttons” and started arguments with others because s/he wanted to get out of the facility. The AV stated that s/he was not hurt following the incident but may have had some redness on her/his body afterwards.

The SP provided the following information:

· The SP stated that on the day of the incident there had been multiple incidents with the AV. Earlier in the day, the AV had pushed another resident to the floor, was using racial slurs and name calling toward other residents. Those incidents were resolved.

· When the AV took the remote from another resident, the SP walked up to the AV and asked her/him to give it back; the AV responded with, “What the fuck are you going to do?”

· The SP stated that the AV broke her/his glasses, pulled out her/his hair. When asked about throwing punches at the AV, the SP could not recall everything but stated that the AV was a strong kid and the SP needed to protect her/himself. The SP could not recall putting the AV in a headlock but stated that s/he sustained multiple hits to the head and had a nosebleed.

· The SP stated that there should have been additional staff instead of just the SP. The other staff persons that were nearby were still in training and they could only observe. The SP believed that the training the facility provided was not sufficient; training on restraints was only 15-20 minutes long and most holds had to be a two-person hold. When asked if the incident was handled pursuant to policies, the SP stated that there should have been a two-person hold. The SP could not recall any hold for which only one staff person could apply; in training every hold had to be by two or more staff persons.

· Looking back at the incident, the SP stated that s/he should have left because the situation was not safe.

P1 provided the following information:

· P1 noted that the AV had been “rowdy” that day. The AV had referred to the SP using the “n” word throughout the day, including toward staff persons. P1 recalled that at some point during the altercation, the AV told the SP, “I told you I was gonna beat your ass.”

· P1 and another staff person that was in training tried to separate the AV and the SP. P1 stated that they were short staffed that day and that staff persons received little training on retraining residents.

P2 provided the following information:

· P2 stated that the AV liked to push people’s buttons and had issues with woman, using racial and homophobic slurs. The AV had two other incidents that day, one before and another right after the incident with the SP. P2 noted that after the incident, the AV had a long scratch down her/his neck, that was superficial in nature and faded away as P2 spoke with the AV.

· According to P2, staff were trained on ignoring taunts from residents, the AV’s team would discuss ways to regulate the AV on a weekly basis and there was regular communication between management and staff persons on the subject.

· P2 stated that the SP had a good work ethic, followed the rules and enforced them, there were no previous concerns with the SP, s/he never laid hands on residents in any manner that was not therapeutic. With respect to the manner in which the SP handled the incident, P2 stated that the SP gauged the situation poorly and interacted with the AV in a “subpar way leading to a very unfortunate outcome.”

Facility documentation showed that the SP received training on restraints, de-escalation, and on the Reporting of Maltreatment of Minors Act.

Conclusion:

A. Maltreatment:

Facility video from the incident on November 23, 2023, recorded the entire incident between the AV and the SP. After the AV refused to give back a video game controller to the SP. The AV was shoved toward a bean bag chair in the process of taking the controller back and the AV proceeded to lunge at the SP. Both the AV and the SP threw punches at one another and despite attempts by other staff persons to separate the two, the AV and the SP continued their physical aggression against one another. In the process of the incident, the SP punched the AV in the back of the head, the AV pulled the SP’s hair out, and the AV broke the SP’s glasses. Despite efforts by P1 and another staff person to bring the altercation to an end, it did not end until the SP placed the AV in a headlock and P1 managed to separate and keep them separated.

The SP, the AV, P1, and P2 provided mostly consistent information regarding their recollection of the incident. The SP and P1 stated that the AV used derogatory terms toward the SP and other residents; P2 confirmed that the AV liked to use derogatory terms toward others at the facility.

Given that the video of the incident showed the AV and the SP traded punches with each other in addition to the SP putting the AV in a headlock, there was a preponderance of the evidence that the SP engaged in conduct that was not accidental causing physical and threatened injury to the AV.

It was determined that physical abuse occurred (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).

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 SP received training on the facility’s restraint policies and on the Reporting of Maltreatment of Minors Act. 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 for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and although the AV had a scratch on his/her neck, it was transitory in nature and was unknown by what action it was caused.

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 conducted an Internal Review of the incident and determined that the SP’s actions were not within policies and procedures. The SP was no longer employed by 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/


state: MN

facility_name: PrairieCare Residential Services

report_date: January 13, 2023

raw_content:
January 13, 2023

Kathleen Cantley, Authorized Agent

Paragon Residential Treatment for Youth, LLC

9400 Zane Avenue North

Brooklyn Park, MN 55443

License Number: 1082863

Investigation Number: 202207016

CORRECTION ORDER

Dear Kathleen Cantley,

A licensing investigation of PrairieCare Residential Services, located at 12915 63rd Avenue North, Maple Grove, MN 55369 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; children's group residential facilities under Minnesota Rules, parts 2960.0130 through 2960.0220; residential mental health treatment under Minnesota Rules, parts 2960.0580 through 2960.0700; and restrictive techniques standards under Minnesota Rule, part 2960.0710. As a result of this licensing investigation a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that an applicant or license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the applicant or license holder.

The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services.

Practices

1. Citation: Minnesota Statues, part 245A.66, subdivision 1.

Violation: The license holder’s practice for maltreatment of minors internal review did not meet requirements. The license holder did not complete an internal review within 30 calendar days when the facility knew an external report of alleged or suspected maltreatment had been made. The license holder was informed of the alleged maltreatment on August 29, 2022 and did not complete an internal review until December 16, 2022.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the practice for internal reviews meets all applicable requirements.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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.

B. Right to Request Reconsideration

If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to:

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14.

If you have any questions regarding this Correction Order, please contact Ginny Benson, Human Services Licensor at 651-431-6957, as soon as possible.

Ginny Benson, MH/SUD/CRF Senior 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/

doc_type: Correction Order


facility_name: Ramsey County Juvenile Detention Center

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: 202401376

Date Issued: June 5, 2024

Name and Address of Facility Investigated:

Ramsey County Juvenile Detention Center
25 W Seventh Street
Saint Paul, MN 55102

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

License Number and Program Type:

1036942-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

Gessner Rivas/Carla Harvieux

Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6616

carla.harvieux@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) told an alleged victim (AV) to get off the phone several times, but the AV declined to end his/her phone call. The SP attempted to hang up the phone and the AV cursed at the SP and slapped him/her. The SP punched and slapped the AV’s face.

Date of Incident(s): February 14, 2024

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 February 28, 2024; from documentation and information at the facility; and through interviews conducted with facility staff persons (P1, P2, P5, and the SP) and the AV.

The facility was a secure 24-hour detention facility for youths 18 years of age or younger who were waiting for court appearances. At the facility, youths participated in discussions led by staff persons, and education, health, and mental health services. There was a video recording system which recorded common areas of the facility and staff persons at the facility wore body cameras that video and audio recorded.

Interviews with a Department of Human Services investigator, facility documentation, videos from the facility’s video recording system, and audio/video recordings from staff persons’ body cameras provided the following information:

· The AV said that at about 12:15 p.m., on February 14, 2024, s/he was making a phone call using the facility’s phone affixed to a wall in the unit in which s/he resided. The SP instructed the AV and other youths to go to their bedrooms, but the AV initially did not hear the SP because s/he was focused on the call and not paying attention. The SP grabbed the AV’s wrist, which hurt the AV and upset him/her, and began pulling the phone away from the AV. The AV pulled back, and the phone slipped and hit the AV’s face. The AV slapped the SP, who then punched the AV’s face. When staff persons observed physical contact between the AV and the SP, they moved between them and held the AV down. The incident occurred quickly and lasted about 30 seconds. After the incident, the AV had bruising and swelling to his/her forehead and neck, but s/he received no medical care for his/her injuries and resided overnight in another unit at the facility before returning to the unit where the incident occurred.

· Body camera audio/video recordings from the cameras worn by the SP, P1, P2, P3, and P4 on the time/date of the incident showed that they each responded to a call for assistance (code 2) at the AV’s unit. Inside the unit, another youth was upset and being redirected by staff persons, the AV was seated in a chair beside the wall phone to the SP’s left, and another youth was walking away from P1 and P2, who were to the AV’s left but in front of the SP. Several staff persons were heard telling the AV to get off the phone and asking the youths to go to their bedrooms. The AV continued the phone call and was smiling and gesturing with his/her hands.

· The SP approached the AV, told him/her to get off the phone, and attempted to take the phone receiver from the AV with his/her right hand, while disconnecting the call with his/her left hand. The SP pulled the receiver from the AV and told the AV to get off the phone and go lie down in a loud voice. The AV raised his/her voice to the SP, cursed him/her, and then slapped the SP. The SP hit the AV several times with his/her right fist, at times reaching over and around P1 and P2, who had grabbed the AV’s arms and were attempting to separate him/her and the SP. The SP followed P1 and P2 as they escorted the AV and continued to swing at the AV. The SP moved away from the AV, P1, and P2, and P3 and P4 stepped between the AV, P1, P2, and the SP. P1 and P2 verbally redirected the AV to go to his/her bedroom and asked the AV to calm, but s/he cursed the SP and said that s/he would “beat” the SP’s ass. The AV did not calm and was placed in a WRAP, which was a restraint system used at the facility for the protection of youths and staff persons when a youth posed a danger to him/herself or others.

· The SP said that s/he went to the unit in which the AV resided because there was a call for assistance with the code 2. Protocol specified that when there was a code 2, youths were to go to their bedrooms, and the SP instructed the AV to end the phone call and go to his/her bedroom. However, the AV declined, cursed the SP, and hit the SP’s face. The SP “reacted” and hit the AV once or twice, but P1 and P2 intervened. The SP realized what s/he had done and left the unit, then the facility. Everything happened very quickly, and the SP was unsure why s/he hit the AV.

· At 1:12 p.m., on February 14, 2024, the AV was assessed by a facility health care professional (HCP) after s/he was released from the WRAP. The HCP documented that the AV had good circulation and vital signs, but the AV told the HCP that s/he had knee and wrist pain. There was redness around one of the AV’s knees that the HCP thought came from pressure of the AV’s pants leg inside the WRAP. The AV had swelling at his/her left eye, and bruising to his/her forehead and temple, but s/he denied that s/he had a headache or changes to his/her vision. The AV was given an ice pack for swelling and a topical ultra strength muscle rub for aches and pains and instructed to tell staff persons if anything changed. The AV voiced no other concerns and there were no other visible injuries.

· P5, a supervisory staff person, said that youths at the facility could have eight telephone calls each day. The SP did not follow protocol when s/he attempted to remove the phone from the AV and should have continued attempting to verbally de-escalate the AV during the incident.

The facility’s Use of Force policy showed that staff persons were to use the minimum amount of force necessary when responding to perceived threats and were to never use force as “punishment.” Staff persons were to attempt to disengage from any situation that might result in physical harm to themselves or others, but if disengagement was not possible, staff persons were to use reasonable response to control and defend against threats or aggressive behaviors.

The facility’s Controlled F.O.R.C.E (First Official Response in a Critical Environment) training showed that staff persons’ responses to the youths’ actions were to be defensive/reactive. Staff persons were not to respond offensively but were to use a reasonable amount of force to control the youths, and not take the youths’ actions personally. Allowed physical holds were described in the Controlled F.O.R.C.E training, but hitting a youth was not listed as an acceptable action.

Facility documentation showed that staff persons interviewed for this report were trained on the facility’s policies and procedures upon hire and the Reporting of Maltreatment of Minors Act prior to the incident. The SP began working at the facility in 2016 and completed a policy review refresher in early 2024.

Conclusion:

A. Maltreatment:

At about 12:15 p.m. on February 14, 2024, several staff persons including the SP responded to the AV’s unit and began redirecting the AV and other youths to their bedrooms. When the SP entered the unit, the AV was making a phone call and declined to follow the SP’s instructions to end the call.

Information was consistent from interviews with the SP and the AV and from audio/video recordings made by the body cameras worn by P1, P2, P3, P4, and the SP, that the AV cursed at the SP and slapped him/her. The SP responded by hitting the AV’s face/head area several times with his/her fists.

P1 and P2 moved quickly between the AV and SP, and held the AV’s arms to prevent him/her from hitting the SP. However, the SP continued to swing at the AV, at times reaching over and around P1 and P2, before realizing what s/he had done, and leaving the unit. The SP said that s/he “reacted” and was unsure why s/he hit the AV, but everything happened very quickly.

The SP’s actions of hitting the AV’s face/neck hard enough to cause swelling to his/her left eye and bruising to his/her temple were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Corrections and was a violation of the facility’s policies and procedures. Given that the AV had bruises and swelling to his/her face and head after the incident, there was a preponderance of the evidence that the SP’s actions were not accidental and caused injury to the AV.

It was 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).

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.

Facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident.

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 for which the SP was responsible was not recurring maltreatment because it was a single incident but was serious maltreatment because it resulted in bruises on the AV’s face/head which were visible after the incident.

The SP was disqualified from providing direct contact services.

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 was licensed by the Department of Corrections was not required to complete an internal review. However, the SP was suspended immediately following the incident and s/he had no further contact with the AV.

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

The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.

Because this facility was licensed by the Minnesota Department of Corrections, a copy of this report was provided to them for their review of the maltreatment determination and to take any necessary licensing actions.

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


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: 202405700

Date Issued: April 25, 2025

Name and Address of Facility Investigated:

Ramsey County Juvenile Detention Center
25 W. Seventh St.
Saint Paul, MN 55102

Disposition: Maltreatment determined as to neglect of the AV by the SP.

Maltreatment not determined as to sexual abuse of the AV by the SP.

License Number and Program Type:

1036942-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
gessner.rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that a staff person (SP) exchanged sexually explicit letters and was suspected of engaging in sexual activity with an alleged victim (AV) at the facility.

Date of Incident(s): June 21, 2024

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2); and subdivision 20:

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.

"Sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, or by a person in a current or recent position of authority to any act that constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on July 9, 2024; documentation from the facility, video security footage from the facility, and through four interviews conducted with a facility supervisor (P1), a facility staff person (P2), the AV’s family member (FM), and the AV. This investigator contacted the SP to request an interview, but the SP did not respond.

The facility was a 24-hour detention facility for youth up to the age of 18 waiting for an initial hearing, trial, court disposition, or placement. Residents at the facility slept in living units called pods which had individual rooms for residents. Residents were able to participate in a variety of programming during their stay including health services and schooling. At the time of this report the AV was 17 years old and residing at the facility awaiting certification for adult court.

The facility’s Personal Associations with Offenders policy required that staff persons maintained professional associations with and a personal detachment from [residents] at all times. Staff persons were not allowed to give or accept special favors to/from residents. The policy stated that sexual misconduct was an egregious violation of professional standards of behaviors between staff persons and residents.

P2 provided the following information:

· On June 21, 2024, P2 witnessed on security cameras, the AV slid a note under the door of the AV’s room which the SP picked up. P2 brought that to the attention of a supervisor. The supervisor reviewed the security footage, and the SP later received a coaching for the note passing.

· P2 noticed that the SP was spending a lot of time in the AV’s pod having lengthy conversations with the AV. The SP would take her/his lunch break in the AV’s pod, the AV would specifically call for the SP, the SP would bring snacks and food for the AV. The AV would refer to the SP and her/his “boo, bae” P2 would ask the AV about that, and the AV would say s/he was just playing.

· P2 confronted both the SP and the AV about some “weird” behavior that P2 had noticed between them; they both told P2 that s/he was mistaken. On June 28, 2024, the AV’s room was searched, and notes between the SP and the AV were found in the AV’s room.

P1 provided the following information:

· The SP was aware of the facility’s policy on professional boundaries. The SP had previously received a coaching due to passing notes with the AV on or about June 21, 2024. P1 noted that no other videos of the SP and AV passing notes were located.

· Staff persons at the facility routinely checked residents’ rooms once per shift. Numerous staff persons had reported that the SP was spending a lot of time in the AV’s pod when s/he was not assigned to work in the pod. Staff persons found 13 double-sided pages of notes that had been passed between the SP and the AV. Both the names of the SP and AV were mentioned in the notes. P1 stated that the notes were turned over to law enforcement (LE). LE did not follow up with the facility about the notes.

· The facility reviewed security footage to determine if there was any sexual contact between the AV and the SP but was not able to find any evidence that the SP and the AV had engaged in sexual activity. Whenever P1 spoke with the AV, the AV only mentioned that s/he wanted the notes back, likely because they described a serious crime that the AV allegedly committed.

· When P1 informed the SP that her/his employment was terminated, the SP asked why. P1 mentioned the notes and the SP asked what was in the notes and then denied any knowledge of notes.

The AV provided the following information:

· The AV first met the SP when the SP was in training, and thought the SP was a cool person because s/he played games with the residents and did not try to “power us.”

· The AV did not recall who was the first to pass a note to the other but stated that s/he wrote letters that were written to someone other than the SP, that were taken out of the AV’s room. The AV did not recall the SP passing any note to him/her.

· The AV stated that the SP did not provide her/him with special treatment that the SP would not provide to other residents at the facility. The AV had no recollection of meeting the SP in any room at the facility. The AV recalled that s/he and the SP would spend time talking about the AV’s future plans. The AV did not want to discuss anything related to having an inappropriate relationship with the SP.

The FM stated that the AV called him/her toward the end of July, 2024, and told the FM that a staff person had passed the AV letters but did not want to say if there was physical contact.

The following information was obtained from facility records, security camera footage, and a copy of the notes passed between the AV and the SP:

· On June 21, 2024, the SP was seen on video in the AV’s pod approaching the AV’s room which at the time was locked. The AV slid a note under the door and the SP put the note in her/his pocket. The SP pulled out her/his phone and appeared to type something while talking to the AV.

· The following day a supervisory staff person delivered a coaching to the SP due to the video from the previous day. The SP apologized for having a phone on the pod, stated that s/he typed a note on the phone because the AV wanted some gum. The SP was reminded not to bring in items for residents.

· On June 28, 2024, two staff persons can be seen entering the AV’s room to conduct a search, shortly thereafter staff persons walked out with documents that turned out to be the notes passed between the AV and the SP. The notes passed between the AV and the SP were not dated. Even though security footage only caught the passing of notes on June 21, 2024, it is likely that note(s) were passed on other dates. The notes contained comments written by both the SP and the AV outlining their future lives together and explicit sexual fantasies, and affections for one another.

· The facility reviewed other video footage where the SP may have interacted with the AV but found no other inappropriate behavior between the SP and the AV prior to the letters being discovered in the AV’s room. Based on the content of the letters, the facility determined that the SP was grooming the AV and acted inappropriate in her/his position which violated facility policy and Prison Rape Elimination Act (PREA) standards.

The facility’s records showed the SP was trained on the Maltreatment of Minors Act and related policies prior to the incident.

Conclusion:

A. Maltreatment:

Information obtained was consistent that the SP and the AV passed notes to one another. In the notes, the SP and the AV wrote to one another about their future plans with one another, their love for one another, and their explicit sexual fantasies with one another. In addition, the SP gave the AV preferential treatment when s/he brought the AV snacks and spent an unusual amount of time socializing with the AV. The AV stated that the SP treated all the residents at the facility the same. According to the AV, s/he and the SP did not pass notes to one another or have any private meetings with one another. The AV acknowledged that the SP and the AV would talk about the AV’s future after the facility.

The SP’s actions did not follow the facility’s policies and procedures in her/his interactions with the AV by failing to maintain a professional relationship on which the SP had been trained. P1 noted that that staff persons had raised concerns about the SP spending a lot of time in the AV’s pod when not assigned to work there. Security video footage caught the AV passing a note to the SP. When the notes were found, it was discovered that the SP had also passed notes to the AV. The notes contained clear evidence of an unprofessional relationship with the AV which the facility’s PREA Investigator found was grooming the AV.

The AV, who was 17 years old when the incident(s) occurred, thought s/he would have future social interaction with the SP, who was older than the AV, after the AV left the facility, so it was likely that the AV’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other attempts to provide him/her with therapeutic services, now and in the future, were hindered. Therefore, there was a preponderance of the evidence the SP’s interactions with the AV were detrimental to the AV’s ongoing mental health and safety which was a failure to supply the AV with necessary care and 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. 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).

Although there were concerns that the SP had engaged in sexual activity with the AV at the facility because of the nature of the notes, given that the facility investigated this concern but found no evidence to support that the SP had sexual contact with the AV, and the AV did not provide any information on the nature of the her/his relationship with the SP or that the SP and the AV had sexual contact, there was not a preponderance of the evidence that the SP had sexual contact with the AV.

It was not determined that sexual abuse occurred ("sexual abuse" means the subjection of a child by a person responsible for the child's care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 (criminal sexual conduct in the first degree), 609.343 (criminal sexual conduct in the second degree), 609.344 (criminal sexual conduct in the third degree), 609.345 (criminal sexual conduct in the fourth degree), or 609.3451 (criminal sexual conduct in the fifth degree). Sexual abuse includes threatened sexual abuse.)

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 SP was trained on the Reporting of Maltreatment of Minors Act and the facilities policies and procedures. 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 neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring because the SP’s pattern of behavior was considered a single incident. The maltreatment for which the SP was responsible was not serious because the AV did not sustain a serious injury as defined by statute from the maltreatment.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph © 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 was licensed by the Department of Corrections and was not required to complete an Internal Review. On June 28, 2024, the SP’s employment at the facility ended.

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.

Because this facility was licensed by the Minnesota Department of Corrections, a copy of this report was sent to them to address any policy violations identified 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/


report_date: October 4, 2023

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: 202304025

Date Issued: October 4, 2023

Name and Address of Facility Investigated:

Ramsey County Juvenile Detention Center
25 W Seventh Street

Saint Paul, MN 55102

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

License Number and Program Type:

1036942-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
gessner.rivas@state.mn.us

651-431-3970

Suspected Maltreatment Reported:

It was reported that a staff person (SP) grabbed an alleged victim (AV) and threw her/him to the ground and the AV sustained a cut lip.

Date of Incident(s): May 11, 2023

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 June 1, 2023; documentation from the facility, medical records, and law enforcement records: and through three interviews conducted with supervisory staff persons (P1 and P2) and the AV. This investigator contacted the SP to request an interview, but the SP did not respond.

The facility was a 24-hour detention facility for youth up to the age of 18 waiting for an initial hearing, trial, court disposition, or placement. Residents at the facility slept in living units called pods which had individual rooms for residents. Residents were able to participate in a variety of programming during their stay including health services and schooling. The AV was residing at the facility awaiting certification for adult court.

The facility’s policies and procedures provided the following information:

· The Safety and Emergency Procedures Use of Force stated that staff persons should use the minimum amount of force necessary. The policy had a Use of Force Model which placed residents into a number of categories depending on their actions, such as: Cooperative, Resister (Active or Passive), and Assailant (Low, Mid or High).

· The policy also had a Use of Force Continuum to guide staff persons on the appropriate response depending on the classification of a resident under the Use of Force Model.

· The facility’s Response to Code Calls policy stated that a “Code 2” was a call for all available staff persons to assist in incidents that could be life threatening, acts that could result in serious physical harm or injury to staff persons, residents, or visitors.

P1 stated that on May 11, 2023, while the AV was secured in her/his room, the AV and the SP exchanged words through the AV’s door window. The SP then opened the door to the AV’s room, and grabbed the AV and forcibly took her/him to the floor. The SP called for a “Code 2” on her/his radio, requesting assistance from other available staff persons. The Superintendent of the facility sent the SP home after having the SP write up a report about the incident; the SP’s employment with the facility was later terminated.

The AV provided the following information:

· The AV was in her/his room and asked the SP if s/he could get some water from the water fountain outside of the room, and the SP told her/him, “No.” The AV said s/he told the SP, “Fuck you,” but did not threaten the SP. The AV stated that the SP then walked to her/his room and said, “Fuck you, I’ll break your neck,” and dared the AV to do something when the SP returned from taking another resident to school.

· When the SP returned, s/he said it was the AV’s turn to clean. The SP opened the door and grabbed the AV, ripped her/his shirt and slammed her/him to the ground, punched her/him the mouth and grabbed the AV’s hair and slammed her/his head against the ground, grabbed her/his left arm and pulled it behind her/his back. The AV stated that the SP mocked the AV for crying and called “the code.”

· The AV stated that s/he got a bloody lip but at first did not want to be checked out because s/he did not think anything was wrong. The AV further stated that s/he was passing out afterwards but did not know that until staff persons told her/him and the last couple of time s/he woke up with a bloody nose. The AV recalled that s/he was taken to the hospital twice.

Video footage of the incident provided the following information:

· The video footage did not have audio. The timestamp showed that the incident began on May 11, 2023, at 10:14 a.m. The SP approached the AV’s room, words were exchanged through the glass window of the AV’s door. The SP walked away from the door five times but returned each time and continued to exchange words with the AV. The SP appeared to be agitated, flailed her/his arms in an aggressive manner and pointed at the AV. At 10:16:06 a.m. the SP walked out of camera view but returned at 10:16:38 a.m. to the AV’s room.

· The SP unlocked the door to the AV’s room, the AV stepped forward and the SP reached with both arms toward the AV’s neck and then grabbed the AV’s t-shirt and swung her/his arm backwards forcing the AV to the floor next to the AV’s room. The AV landed on her/his left side and the SP got on top of the AV, the AV’s head can be seen bouncing up and down a number of times; twice, the AV’s head can be seen hitting the floor. The AV was turned over to her/his right side, and the SP could be seen putting her/his knee on the AV’s back, and the SP pinned the AV’s left arm behind the AV’s back towards her/his right shoulder.

· While the SP was on top of the AV, the SP could be seen pushing the AV down into the floor a number of times, the AV did not appear to be fighting back. At some point during the altercation the SP called a “Code 2” over the radio and other staff persons began to arrive at 10:17:55 a.m. One staff person tapped the SP on the back and the SP stood up and walked away from the AV, a staff person checked on the AV who then stood up and was placed back in her/his room at 10:18:40 a.m.

The SP submitted a report regarding the incident and provided the following information:

· The report submitted by the SP stated that the AV was shouting through her/his door. While the SP escorted another resident to a classroom, the SP stopped at the AV’s door and asked the AV to stop and calm down and upon the SP’s return, the AV would get a chance to come out and clean. The SP returned and opened the AV’s door and the AV “acted as if [s/he] was going to lunge and attack me.”

· The SP then noted that before the AV had a chance to do so, s/he took the AV down to the ground and held [her/him] down there,” and called a Code 2 holding the AV there until support arrived.

Facility records regarding the incident provided the following information:

· Other staff persons responding to the Code 2 noted that the AV was secured on the floor next to the AV’s room, was not resisting, and was walked back into her/his room.

· A facility nurse (N) noted that the AV was yelling and threatening staff persons, the N was informed that the AV was bleeding, The N noticed there was a minimal amount of blood on the floor outside of the AV’s

room. The AV did not allow the N to make an assessment through the door window and the AV stated, “I am fine. I didn’t get hurt... my lip was bleeding [it’s] not bleeding anymore.”

· After the AV was deescalated, the N was able to observe the AV through the window and noticed a small wound on the inside of the AV’s upper lip, approximately 0.5 centimeters. The N did not observe any other signs of injuries, as s/he observed the AV walk around in the room without a shirt.

· Later in the day, the AV had fallen asleep on the floor of her/his room and was awoken at 3:15 p.m. by a staff person after calling out the AV’s name several times. The AV was evaluated by an N later that evening. The AV stated that s/he had been hit by a car “not too long ago,” from which s/he had pain in her/his back and legs. The AV noted that the SP had punched her/him in the upper lip, twisted her/his left arm back and above her/his right shoulder, landed her/him on the ground and grabbed her/his hair, and knocked her/his head on the floor two to three times. The AV denied having any headaches, neck pain, or dizziness, but was experiencing pain in her/his back, left arm and lower right leg. The AV stated that s/he was “seeing stars.”

· Later that evening around 7:15 p.m., the AV was again found on the floor, did not how s/he got there, and was confused. A Code 2 Medical was called for the AV. The AV was taken to the hospital and admitted at 8:29 p.m.

· In the following days, on numerous occasions the AV was found “unresponsive” in her/his room, staff persons tried to wake the AV by calling her/his name and/or tapping her/him on the shoulder and the AV would not respond. Each time the AV was found like this, the N checked in on the AV and found the AV’s vitals to be within normal limits. On May 12, 2023, the AV was moved to a room with a camera and placed on 15-minute overnight checks. On May 13, 2023, after being found “unresponsive” to staff persons calling the AV’s name and or tapping the AV on the shoulder, with dried blood by on his face, the AV was moved to a different room with a camera. On May 14, 2023, the AV was again found in her/his room “unresponsive” with dried blood near her/his face. On May 15, 2023, at 1:00 a.m. the AV was again found “unresponsive,” with blood on the floor next to the AV. Paramedics were called, and the AV was taken to the hospital for evaluation. The AV was cleared at the hospital and returned to the facility around 4:14 a.m.

Medical records provided the following information:

· The AV was admitted to Regions Hospital on May 11, 2023, at 8:29 p.m. for evaluation after the altercation with the SP. The AV expressed s/he was experiencing pain in the right shin and mild pain in the jaw, and left forehead. A physical exam noted that the AV had a small hematoma (bruise) and tissue swelling in the right shin. A neurologic exam showed no cause for concern, a computerized tomography (CT) scan was normal, an electrocardiogram (EKG) did not reveal any cause for concern, and a thoracic spine x-ray was performed due to the AV’s complaints of tenderness after the altercation; x-ray results were normal.

· On May 15, 2023, the AV was again admitted at 1:45 a.m. for repeated episodes of syncope (fainting). Medical professionals noted a small amount of blood coming from the AV’s nose. The AV noted that s/he had pain in her/his left clavicle, left shoulder, and neck pain since “falling” in her/his room (hospital records were not clear if this meant during the incident with the SP or a different incident). A physical exam noted that the AV had tenderness in her/his cervical spine but was otherwise normal. EKG results were unchanged from the previous one conducted on May 11, 2023. A CT scan of the cervical spine and head showed no abnormalities. An x-ray of the AV’s shoulder was normal. An ultrasound of the AV’s inferior vena cava showed normal respiratory variation. The AV was discharged from the hospital at 3:31 a.m.

P1 provided the following information:

· At the time of the incident, P1 was an administrative staff person at the facility. When the Code 2 call came over the radio P1 was in a meeting with other management level staff persons, which included P2. P1 pulled up the video footage from the pod where the incident occurred and saw that the situation had been resolved. P1 then rewound the video footage to when the incident began.

· P1 watched the incident from beginning to end and went to the pod, found the SP sitting at her/his desk, the AV was in her/his room and other staff persons were trying to calm her/him so that medical staff persons could look at her/him. The SP was removed from the area and escorted out of the pod and was informed s/he would be sent home but first s/he was instructed to write a report.

· The video of the incident was reviewed again to determine if the level of force used was appropriate. The following Friday May 12, 2023, the SP was informed that her/his employment was terminated. P1 stated that the SP did not follow policies and practices because the AV was secured in her/his room and was not posing a threat to self or others, the SP’s actions were “way outside the use of force” policy.

P2 provided the following information:

· P2 stated that staff persons were trained to recognize the various subject types of residents to guide staff persons on the appropriate force to use. The AV appeared to be cooperative and in the “Use of Force Continuum, the use of hands on a cooperative [person] is not within the appropriate use of force.”

· P2 stated that in review of the video, “It was apparent that the action was extreme, shocking, and it was going to be a problem.”

Conclusion:

A. Maltreatment:

Information showed that the AV was secured in her/his room and did not pose a threat to self or others when the AV and the SP had an exchange of words. Video footage showed that the SP then opened the AV’s door and the SP reached with both arms toward the AV’s neck and then grabbed the AV’s t-shirt and swung her/his arm backwards forcing the AV to the floor next to the AV’s room. The AV landed on her/his left side and the SP got on top of the AV, the AV’s head can be seen bouncing up and down a number of times; twice, the AV’s head can be seen hitting the floor. The AV was turned over to her/his right side, and the SP could be seen putting her/his knee on the AV’s back, and the SP pinned the AV’s left arm behind the AV’s back towards her/his right shoulder. The SP was on top of the AV and was pushing the AV down on the floor while the AV did not appear to be fighting back. Video footage of the incident and statements provided by P1 and P2 corroborated that SP acted outside of the facility’s policies and practices regarding the use of force because there was no need for the SP to open the AV’s door and the SP’s use of force was inappropriate. The AV sustained a cut lip. Later that day, the AV was found more than once “unresponsive” to staff persons calling the AV’s name to wake up. The VA went to the hospital. The VA had a bruise and swelling on his/her shin. The VA then returned to the facility. Three days later, the AV retuned to the hospital for repeated episodes of syncope (fainting) which occurred several times in the days following the incident. The AV was given testing and then returned to the facility.

Given that the facility’s policies and practices to use the minimum amount of force necessary were not followed by the SP when s/he engaged the AV, that the testimony provided by staff persons that the SP’s actions were “way outside the use of force,” “extreme,” and “shocking,” and that the AV sustained physical injuries, there was a preponderance of the evidence that the SP’s conduct was not accidental and caused the AV physical injury.

It was determined that physical abuse occurred (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).

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 SP was trained on the facility’s relevant policies and the Reporting of Maltreatment of Minors Act prior to the incident. 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 for which the SP was responsible was not recurring maltreatment because it was a single incident but was serious maltreatment because the AV sustained physical injuries. The SP was disqualified from providing direct contact services.

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 reviewed the actions of the SP and determined that the SP’s actions were not within policies and practices and terminated the SP’s employment.

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

The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal.

Certification:

The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.

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


facility_name: Salvation Army Booth Brown House Services (The)

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

doc_type: Document


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


facility_name: Sol House


facility_name: Southeast Regional Crisis Center Nexus

report_date: October 10, 2025

raw_content:
October 10, 2025

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 North

Plymouth, MN 55441-6447

License Number: 1108377 (CRF)

Report Numbers: 202402510, 202403620, and 202502247

CORRECTION ORDER

Dear Katie Perzel:

On June 9, 2025 through 11, 2025, the Department of Human Services (DHS) conducted a licensing review and investigation at your facility located at 2121 Campus Drive SE, Rochester, Minnesota, 55904-4733. As a result of this visit, DHS determined that you are in violation of 7 of the children’s residential facilities rules and statutes. 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 did not follow licensing rules and statutes, as described below.

PRACTICES

1. Violation: One of five grievances reviewed did not meet requirements. There was no documentation that the person filing the grievance received a response within the required five day timeline.

Rule Violated: Minnesota Rules, part 2960.0080, subpart 18, item A.

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

PERSONNEL FILES

2. Violation: Two of two personnel files reviewed for requirements governing orientation training did not meet requirements in the following ways:

a. There was no documentation of trainings being completed prior to having unsupervised contact with residents:

i. Emergency procedures, including evacuation routes, emergency telephone numbers, severe storm and tornado procedures, and location of facility alarms and equipment (personnel file numbered 2);

ii. Cultural diversity, gender sensitivity and culturally specific services (resident file numbered 2); and

iii. Data practices regulation and issues (resident files numbered 2 and 3);

b. There was no documentation of trainings being completed within 72 hours of first providing direct contact services:

i. Vulnerable adult maltreatment reporting requirements and definitions (personnel file numbered 2)

ii. The license holders program abuse prevention plan (personnel file numbered 2); and

iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services (personnel file numbered 2).

Statute/Rule Violated: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, part 2960.0100, subpart 3, item A.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 24, 2022.

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

RESIDENT FILES

3. Violation: One of three resident files reviewed for requirements governing resident information did not meet requirements (resident file numbered 3). The file did not contain documentation that the license holder gathered the following information about the resident:

a. The race or cultural heritage and languages the resident speaks and writes was not dated, so the DHS licensor was unable to determine if it was completed within five working days of admission;

b. The spiritual or religious affiliation of the resident and the residents family; and

c. The placing agency’s case plan goals for the resident.

Rule Violated: Minnesota Rules, part 2960.0070, subpart 3, item B.

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 24, 2022.

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

4. Violation: One of three resident files reviewed for requirements governing inventory and handling of resident property did not meet requirements (resident file numbered 1). The license holder completed the inventory of the resident’s personal property, but did not have two staff sign off on the inventory after the resident did not sign.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 24, 2022.

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

5. Violation: One resident file reviewed for requirements governing vulnerable adult orientation did not meet requirements (resident file numbered 4). There was no documentation to demonstrate that the resident was oriented to the program abuse prevention plan.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 24, 2022.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult orientation and individual abuse prevention plans meet all applicable requirements.

6. Violation: One of three resident files reviewed for requirements governing health care services did not meet requirements (resident file numbered 1). There was no documentation that the license holder contacted a newly admitted resident’s prescribing medically licensed person to verify information regarding prescribed medication, including instructions about how the medication must be administered, the symptoms that the medication will alleviate, and the symptoms that would warrant consultation with the physician.

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

Repeat Violation: This is a repeat violation. The license holder was cited for a similar violation in a Correction Order dated June 24, 2022.

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

7. Violation: One resident file was reviewed for requirements governing a no-eject discharge (resident file numbered 1) and did not meet requirements. There was no documentation the license holder determined whether the license holder, treatment team, interested persons, if any, and the resident can develop additional strategies to resolve the issues leading to the discharge and to permit the resident an opportunity to continue to receive services from the license holder.

Rule Violated: Minnesota Rules, part 2960.0090, subpart 2.

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

If you fail to correct the violations specified in the Correction Order within the prescribed timelines 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 a corrective action ordered must be sent to DHS Licensing at:

1. By secure email to: maddy.moore@state.mn.us; or

2. By mail to: Commissioner, Department of Human Services

ATTN: Maddy Moore

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:

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 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

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Questions

If you have any further questions regarding this matter, you may contact Maddy Moore, Senior Licensor, at 651-431-4585.

Sincerely,

Maddy Moore, Senior 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: October 9, 2024

raw_content:
October 9, 2024

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 N. STE 500

Plymouth, MN 55441

License Number:   1108377

Dear Michelle Murray:

On August 22, 2024, the Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of the citation in the Correction Order (Attachment A) issued to you by the Department of Human Services on August 8, 2024. You requested reconsideration only of violations b and c of the citation. Violations a and d of the citation are therefore final and not within the scope of this review.

Citation 1: Violation: The license holder did not meet critical incident reporting requirements. The following incidents met the definition of a critical incident and were not submitted to DHS within 10 days of learning of the incident:

a. An incident dated July 29, 2023, was submitted on June 2, 2024;

b. An incident dated September 1, 2023, was submitted on June 3, 2024;

c. An incident dated May 26, 2024, was submitted on June 18, 2024; and

d. Two incidents dated July 6, 2024, were submitted on July 27, 2024.

Request for Reconsideration. You submitted a letter requesting reconsideration in which you indicate the program was in compliance with the applicable law at the time the citation was issued. With regard to item b, you indicate the program reported the incident on September 26, 2023, and the report sent on June 3, 2024, was a duplicate of the same incident. With regard to item c, you indicate that although you reported the incident to the Office of Ombudsman on June 3, 2024, you believe the incident did not require a critical incident report to DHS because the injury did not require hospitalization or serious medical treatment. You acknowledge that the incident involved a head injury that required medical attention. You submitted supporting documentation.

Reconsideration Determination. Under Minnesota Rules, part 2960.0080, subpart 17, item A, the license holder must report critical incidents and the maltreatment of a resident according to items A to D. Item A requires that the license holder report critical incidents of a serious nature that involve or endanger the life or safety of the resident or others to the commissioner of human services within ten days of the day of the occurrence on forms approved by the commissioner of human services or corrections. The license holder must maintain records of all critical incidents on file in the facility.

Under Minnesota Rules, part 2960.0020, subpart 24, “critical incident” means an occurrence which involves a resident and requires the program to make a response that is not part of the program’s ordinary daily routine. Examples of critical incidents include, but are not limited to, suicide, attempted suicide, homicide, death of a resident, injury that is either life-threatening or requires medical treatment, fire which requires fire department response, alleged maltreatment of a resident, assault of a resident, assault by a resident, client-to-client sexual contact, or other act or situation which would require a response by law enforcement, the fire department, an ambulance, or another emergency response provider.

With regard to violation b, there is no record of the report being submitted until June 3, 2024, and no documentation of an earlier report was provided. Even if the report had been submitted on September 26, 2023, it would not have met the requirements of the rule. The incident occurred on September 1, 2023, which would have been twenty-five days prior to the date of the report, and the rule requires that critical incidents be reported within ten days of the occurrence.

With regard to violation c, you acknowledge the incident involved an injury that required medical attention, and the definition of “critical incident” includes, but is not limited to, an injury that “requires medical treatment.” The definition of “critical incident” means an occurrence which requires the program to make a response that is not part of the program’s ordinary daily routine. According to the Critical Incident Reporting Form you submitted on June 18, 2024, the individual involved in the incident sustained a head injury and was assessed via a telehealth visit with an emergency room physician. Also, an email from the program to DHS dated June 18, 2024, indicated the program would follow up with a critical incident report.

There is therefore sufficient evidence to support the violations and they are affirmed, with the modification that the correct authority for the citation is Minnesota Rules, part 2960.0080, item A, and Minnesota Rules, part 2960.0020, subpart 24. The correction order incorrectly cited Minnesota Statutes, section 245I.13 as the authority for the citation.

Disposition: The Commissioner has reviewed the request for reconsideration and all of the information submitted in response to the correction order. The Commissioner finds there is sufficient evidence to support the citation, and it is affirmed. This is a final agency decision.

Sincerely,

Frances Simon Standing, Attorney

Legal Counsel’s Office

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/