facility_name: Nexus-Mille Lacs Family Healing, New Trails GH

report_date: September 26, 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: 202506895

Date Issued: September 26, 2025

Name and Address of Facility Investigated:

Nexus-Mille Lacs Family Healing New Trails GH
312 Elm St S
Onamia, MN 56359

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

License Number and Program Type:

1056498-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
651-431-6616

carla.harvieux@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) did not check on an alleged victim (AV) in his/her bedroom for about seven hours. During the time the AV was not supervised, the AV left the facility and was located three days later in the community.

Date of Incident(s): June 22, 2025

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

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on August 27, 2025; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1, P2, and the SP), the AV, and the AV’s guardian (G). DHS received the concerns investigated in this report on July 31, 2025.

The facility provided services to youths 14-19 years of age and offered 24 hour a day supervision with individualized coaching and mentoring. The facility’s programs were designed to keep families engaged throughout the treatment process and ensure that those served by the program were wrapped with necessary supports. The facility had a video recording system which recorded interior common areas of the facility, but the system did not have sound or record the facility's exteriors.

Facility documentation showed that the AV was diagnosed with anxiety and was vulnerable to maltreatment. When the AV was stressed, s/he might have difficulty making well thought out decisions and might seek concerning methods to calm him/herself. The AV had a history of leaving facilities without the knowledge or supervision of staff persons and might use substances when s/he was unsupervised in the community. The AV was intelligent and resourceful.

Interviews with this investigator, facility documentation, records from a law enforcement agency, and the facility’s Internal Review, provided the following:

· The AV said that on the date of the incident, s/he felt fine and told the SP that s/he was going to his/her bedroom to relax. The SP “never” checked on the AV that day, and s/he left the facility at about 11 a.m. by climbing out of his/her bedroom window (which had no alarm), then jumping to the ground. The AV was not injured and was surprised that staff persons did not see him/her when s/he crossed the facility grounds while leaving. It was common that staff persons did not check on youths in their bedrooms or other parts of the facility and did not search the youths or their belongings when the youths returned to the facility after time in the community. Staff persons at the facility were not engaged with the youths and were inconsistent when they enforced the facility’s policies and procedures, according to the AV.

· The SP said that on the date of the incident, P1 worked with him/her and took several youths on outings, which meant that the SP remained at the facility to supervise the youths there. Staff persons rotated taking youths on outings so that they were not continuously the staff person who went on outings or the staff person who remained at the facility to supervise the youths. The AV told the SP that s/he did not feel well several times, took a shower at about 1 p.m., and then went to lie down in his/her bedroom. The SP had a good relationship with the AV and did not think that the AV would leave the facility, so s/he did not check on the AV in his/her bedroom until about 7 p.m., to give the AV time to rest and sleep. When the SP opened the door to the AV’s bedroom, s/he discovered that the AV was not there. The bedroom window was open, so the SP thought that the AV left through the window. The SP immediately notified supervisory staff persons and called 9-1-1 to notify the law enforcement agency that the AV left the facility without supervision. The SP felt sick to his/her stomach and was very worried about the AV. No information showed that the SP evaluated the AV for signs/symptoms of illness prior to the AV entering his/her bedroom.

· The Resident Count sheet for June 22, 2025, showed that the SP documented checks on the youths at the facility that day. The SP marked that s/he checked on the AV regularly as required from 6:30 a.m. to 2:30 p.m., but did not check on the AV between 3 p.m. to 7 p.m.

· P1 worked the shift with the SP on the date of the incident and took youths on outings that day, while the SP stayed at the facility to supervise the youths who did not go on outings. After P1 returned to the facility at a time s/he did not recall, but between 7 and 9 p.m., s/he realized that s/he had not seen the AV since returning, and s/he and the SP checked on the AV, then realized the AV was not in his/her bedroom. P1 and the SP searched the facility and its grounds, but the AV was not there. P1 called 9-1-1 and a supervisory staff person to let them know the AV left the facility without supervision.

· Records from the law enforcement agency showed that the agency responded to the call from the facility, and on June 25, 2025, the AV was found in the community, then taken to a secure facility. The AV did not return to the facility and later began residing in a different facility that provided similar services. No information showed that the AV sustained an injury or whether s/he used substances when s/he exited the facility or while s/he was unsupervised in the community.

· P1, P2 (who was a supervisory staff person), and the SP, provided consistent information that staff persons were to check on the youths every 15-30 minutes depending on the youths’ individual needs and when they were not within the immediate sight of staff persons. According to P2, when the youths were in their bedrooms or lying in their beds, staff persons were to check on the youths every 15-30 minutes to ensure that the youths were present and look for chest rise/fall or other signs to confirm the youth was breathing and not in distress. On the date of the incident, staff persons were in ratio and supervising an appropriate number of youths. P2 added that if a youth might be ill, staff persons should check on them frequently to determine if the youth required additional care.

· After the June 22, 2025, incident, P2 reviewed video recordings of the SP’s shift and observed that the AV entered his/her bedroom just before 1 p.m. and was last seen on the recording at about 1:30 p.m., when s/he opened the bedroom door and looked up and down the hall. P2 thought that the AV was possibly looking for the SP in the hall and probably left the facility through his/her bedroom window shortly after checking the hall. The recordings showed that the SP intermittently sat at a desk in the hall periodically and sometimes used his/her cell phone during the shift. The SP checked on some of the youths during the shift, but staff persons did not check on the AV until 7:33 p.m., which meant that staff persons did not check on the AV for about seven hours.

· P2 said that the facility did not report the incident to DHS in a timely manner and thought that the lapse occurred because the incident occurred at a time when there was turnover among administrative staff persons. Prior to the incident, there were previous concerns regarding the SP’s use of his/her cell phone on the floor and P2 had previously discussed cell phone use on shift with the SP.

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.

Conclusion:

A. Maltreatment:

Information was consistent from the AV, P1, P2, and the SP, that on June 22, 2025, the AV left the facility without the knowledge or supervision of a staff person. The AV said s/he exited the facility through his/her bedroom window.

According to P1, P2, and the SP, staff persons were to check on youths who resided at the facility every 15-30 minutes, depending on the supervision needs of the youths. The SP said that s/he did not check on the AV in his/her bedroom because the AV told the SP that s/he did not feel well, and video recordings from the facility confirmed that the AV entered his/her bedroom and closed the door at about 1:30 p.m. on the date of the incident. There were no further recordings of the AV, but recordings showed the SP intermittently sitting at a desk, using his/her cell phone, and checking on other youths periodically during the shift.

When the SP and P1 checked on the AV at 7:33 p.m., they observed the AV was gone, and P1 called 9-1-1. Records from the law enforcement agency showed that the AV was found on in the community on June 25, 2025.

Although no information showed that the AV was injured or used substances when s/he left the facility or was unsupervised in the community, given that the SP said that the AV told him/her that s/he did not feel well and entered his/her bedroom at about 1:30 p.m., but the SP did not check on the AV for an extended time, which was not consistent with facility policies and procedures and inconsistent with the actions of a professional caregiver in a DHS licensed facility, there was a preponderance of the evidence that there was a failure to supply the AV with health or other care required for 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).

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 responsible for the AV’s supervision when the incident occurred and a video recording from the facility’s video recording system showed that the SP did not check on the AV for about seven hours. 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

It was determined that the substantiated neglect 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 no information showed that the AV was injured when s/he left the facility without supervision.

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 which determined that their policies and procedures were adequate but were not followed. The facility revised its Reporting of Maltreatment Policy to more clearly show what steps should be taken within specified time frames to ensure that reports of possible maltreatment were made quickly and retrained staff persons on completing proper well-being checks. In addition, P2 (or a designated supervisory staff person) was instructed to randomly review portions of video recordings for each shift to ensure that staff persons properly completed checks on the youths. The SP and P1 each received written corrective actions.

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 the facility is licensed by the Minnesota Department of Corrections, a copy of this report was forwarded to them for their review of possible licensing violations.

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

report_date: December 2, 2024

raw_content:
December 2, 2024

Michelle Murray, Authorized Agent

Nexus Mille Lacs Family Healing, New Trails GH

505 Highway 169 N Ste. 500

Plymouth, MN 55441

License Number: 1056498 (CRF)

CORRECTION ORDER

Dear Michelle Murray,

On May 24, 2024, a certification review of Nexus Mille Lacs Family Healing, New Trails GH, located at 312 Elm Street, Onamia, MN 56359 was conducted to determine compliance. This review was conducted to determine compliance with state and federal laws and rules governing the provision of The Family First Prevention Services Act under Minnesota Statues 245A.25. As a result of this certification review a Correction Order is being issued.

LICENSING VIOLATIONS

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

PERSONNEL FILES

1. Violation: Two of three personnel files reviewed for requirements governing orientation training did not meet requirements (personnel files numbered 2 and 3). The staff did not receive human trafficking training prior to having direct contact with youth.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 5, paragraph (f).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the orientation and training meets all applicable requirements. Within 30 days of receipt of this order, submit documentation demonstrating personnel files numbered 2 and 3 have received human trafficking training.

2. Violation: Three of three personnel files reviewed for requirements governing ongoing training did not meet requirements. Staff did not receive the following training on an annual basis:

a. Concepts of trauma informed care and how to provide services according to these concepts for calendar year (CY) 2023 (personnel file numbered 1) and CY 2024 (personnel files numbered 1 and 3); and

b. Human trafficking training for CY 2022 (personnel files numbered 2 and 3).

Statute Violated: Minnesota Statues, section 245A.25, subdivision 3, paragraph (h) and subdivision 5, paragraph (f).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that ongoing training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating personnel files numbered 1 through 3 have received the required annual training.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines the Commissioner may rescind certification pursuant to Minnesota Statutes, section 245A.25, subdivision 9.

Submissions required as part of a corrective action required must be sent to DHS Licensing at:

1. By secure email to: madelyn.gilbertson@state.mn.us; or

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

ATTN: Maddy Gilbertson

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 Gilbertson, Senior Licensor, at 651-431-4585.

Sincerely,

Maddy Gilbertson, 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: Nexus-Mille Lacs Family Healing, Willow Trails GH

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


facility_name: North Homes Boys TNT

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.”

Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”

Report Number: 202502493 and 202503901

Date Issued: May 15, 2025

Name and Address of Facility Investigated:

North Homes Boys Teens in Transition
619 NW 20th Ave
Grand Rapids, MN 55744

Disposition: Maltreatment Determined as to neglect of five alleged victims by a staff person. Substantiated as to neglect of three vulnerable adults by a staff person.

License Number and Program Type:

1028358-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

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

Suspected Maltreatment Reported:

It was reported that a staff person (SP) took five alleged victims (AV1-AV5) and one vulnerable adult (VA1) on a walk. After they returned from the walk, AV1-AV5 and VA1 appeared “high” and there was concern that the SP let AV1-AV5 and VA1 use a “vape” or “cart” containing tetrahydrocannabinol (THC) while on the walk.

Date of Incident(s): March 22, 2025

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

Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so.

Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so.

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a):

The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct.

Summary of Findings:

Pertinent information was obtained during site visits conducted on March 31 and April 1, 2025; from documentation at the facility; and through 12 interviews conducted with two staff persons (SP and P1), a supervisory staff person (P2), AV1-AV6, and VA1-VA3. AV1’s-AV6’s guardians were contacted via phone and US mail and notified of this investigation, but none had additional information to provide. VA1-VA3 were not subject to guardianship.

The facility provided services to youth aged 16 to 21. According to documentation from the facility, the SP began working at the facility on December 12, 2024, and on March 22, 2025, the SP worked from 8 a.m. to 8 p.m.

According to the clients’ Group Residential Case Plans, AV1-AV3 were assessed as “low-risk” for substance use and abuse. VA3 was also assessed as “low risk,” however, his/her diagnoses at intake included cannabis dependence. AV4-AV6 and VA2 were assessed as “medium-risk” for substance use and abuse. VA1 was assessed as “high-risk” for substance use and abuse. AV1-AV6 and VA1-VA3 were each under 21 years old.

P1 provided the following information in an interview and in the facility’s Internal Review:

· On March 22, 2025, the SP took six youth, AV1-AV5 and VA1, on a walk which P1 thought was “odd” because the youth were doing chores, it was almost time for them to go to bed, and they did not like to do recreational activities. At the time, the SP “insisted” s/he take the youth on a walk, and P1 stated that “something felt weird” about it.

· After the group left on the walk, AV6 approached P1 and told him/her that s/he “knew” why the youth wanted to go on a walk and that the youth used THC “carts” and nicotine “vapes” while on walks, but that the SP did not know about it. VA3 then told P1 that youth used “carts” and “vapes” on walks and that the SP did know about it. VA3 also told P1 that in the past s/he used the SP’s vapes but did not say anything because s/he wanted to continue to do so.

· When the youth and the SP returned from the walk, they were all “visibly [high]” and were slurring their speech, apart from AV5, who did not seem under the influence. VA1 had “really red eyes” and AV3 could not keep his/her head up. P1 sent all the youth to their rooms and called P2 and a facility nurse. The nurse told P1 to monitored the youth. P1 did so and also did “extra checks” during the overnight. The next day, the youth talked to P2 and acknowledged using the SP’s vape and THC carts.

P2 provided the following consistent information in an interview and in the facility’s Internal Review:

· On March 22, 2025, P1 called P2 and said that six youth returned from a walk with the SP and seemed “high.” P2 told P1 to call nursing staff for instructions on what to do next. P2 also took the SP off the facility schedule and found another staff person to cover his/her shift scheduled for following day.

· The next day, March 23, 2025, P2 spoke to AV1-AV5 and VA1 and also AV6, VA2, and VA3. AV1-AV4 and VA1 each stated that while on the walk with the SP, each used the SP’s “vape” with THC. AV5 stated that s/he did not use it but AV1-AV4 and VA1 stated that AV5 did so. When P2 spoke to AV6, VA2 and VA3, each stated that they used the SP’s “vape” in the past.

· On March 24, 2025, P2 so to the SP about the incident, and the SP acknowledged that s/he allowed the youth to use his/her “vape,” but that it only contained nicotine and not THC.

AV1-AV6 and VA1-VA3 each provided the following consistent information in their respective interviews and in the facility’s Incident Report:

· AV1-AV4 and VA1 each stated that on March 22, 2025, they went on the walk with the SP and while on the walk, each used the SP’s “vape” and/or “cart” that contained THC. AV5 stated that s/he did not smoke while on the walk. AV1 stated that the SP let youth use the “vape” weekly; AV2 stated that the SP let youth use the nicotine vape whenever s/he worked at the facility; AV3 stated that the SP had let residents use the vape for “months;” AV4 stated that the SP did not let AV4 use his/her “vape;” AV5 stated that the SP let residents use his/he “vapes” and THC “carts;” and VA1 stated that the SP let him/her use his/her THC “pen” and “vape” “every time” the SP worked.

· AV6, VA2, and VA3 each stated that they did not go on the walk on March 22, 2025. AV6, VA2, and VA3 each also stated that the SP gave nicotine “vapes” and THC “carts” to youth in the past. AV6 stated that it had been going on for “the last couple weeks;” VA2 stated that it had been going on for “about two months;” and VA3 stated that it had been going on since January 27, 2025. The youth stated that the SP allowed them to use the “vapes” and “carts” at the facility, outside, and in the van while the SP drove.

The SP provided the following information during the interview and in the Internal Review:

· The SP allowed the youth to use their personal THC and nicotine vapes on walks, during outings, and at the facility. The youth obtained the THC and nicotine vapes from school or work and brought them to the facility in their backpacks and kept them hidden in their rooms. At the beginning of his/her employment at the facility, the SP “shut it down” and did not allow the youth to use them, but eventually the SP “turned a blind eye” to the behavior because there was “nothing I could do about it to stop them.” The SP stated that it also “got to a point” where s/he stopped writing up the youth for having nicotine and THC vapes because s/he “did not know what to write anymore.” The SP stated that the facility felt “inescapable” and that it was “impossible” to enforce the rules because the youth “did not care about the consequences.”

· The SP denied providing THC vapes or cartridges to any youth. but stated that on one occasion s/he gave VA3 a “hit” off his/her personal nicotine vape while at the facility. The SP stated that it was a “mistake” and that s/he was “entirely remorseful.” However, the SP provided conflicting information during the

facility’s Internal Review. On March 24, 2025, the SP stated that s/he allowed the youth to use his/her “vape” but stated that it contained nicotine and not THC.

· The SP thought that the youth might say that the SP gave them the THC and/or nicotine vapes/carts because the youth did not want to get in trouble and/or “rat out” the other youth for bringing the items into the facility.

· The SP stated that s/he was trained on the facility’s policies regarding drugs and nicotine at the facility. The SP added that when s/he used his/her personal nicotine vape while working, s/he did so in his/her car.

According to the facility’s Drug-Free Workplace policy,

[The facility] prohibited the unlawful manufacturing, distribution, sale, dispensing, possession, transfer or use of alcoholic beverages, intoxicants and narcotics, illegal or unauthorized drugs (including marijuana), ‘look-alike’ (simulated) drugs, and/or any related drugs paraphernalia on its premises, facilities, or workplaces.

The SP, P1 and P2 were each trained on the facility’s Drug-Free Workplace policy, the Reporting of Maltreatment of Vulnerable Adults Act, and the Reporting of Maltreatment of Minors Act, and the youths’ plans.

Relevant Rule and Statute:

Minnesota Statute, section 209.6855, subdivision 1, paragraph (a) states in part that an individual may not give any product containing or delivering nicotine to an individual under 21 years of age.

Minnesota Statute, section 342.09, subdivision 1, paragraph (b), clause (7) states in part that an individual may not give cannabis to an individual under 21 years of age.

Conclusion:

Information from AV1-AV6, VA1, P1, and P2, was consistent that on March 22, 2025, the SP took AV1-AV5, and VA1 on a walk and when they returned each appeared to be under the influence of a substance with the exception of AV5. AV1-AV5, and VA1 each stated that when they were on the walk the SP allowed them to use the SP’s vape/carts that contained THC and/or nicotine. In addition, information from AV1-AV6, VA1, and VA2 was consistent that there were multiple other times at the facility and in the van when the SP allowed the youth to use the SP’s vape/cart that contained nicotine/THC.

The SP denied allowing the youth to use his/her vapes/carts with marijuana. Although during the interview the SP denied giving the youth his/her vape/cart with nicotine, with the exception of one occasion when s/he allowed VA3 to use his/her personal nicotine vape, during the Internal Review, the SP stated that s/he allowed the youth to use his/her vape with nicotine.

The SP stated that the youth obtained the vapes/carts with nicotine and/or marijuana from school or work. The SP stated that initially s/he did not allow the youth to use their own vapes/carts but eventually allowed them to do so while on walks, during outings, and while at the facility, and did not do anything to stop the youth from

doing so. In addition, the SP stated that it “got to a point” where s/he stopped writing up the youth for having nicotine and THC vapes because s/he “did not know what to write anymore.”

Although the SP denied allowing AV1-AV6, and VA1-VA3 to use his/her vape/cart that contained marijuana and/or nicotine, given that AV1-AV6, and VA1-VA3 provided consistent information that the SP did so; that their own admissions to using marijuana/nicotine exposed each to possible ramifications; and that P1 observed intoxicated behaviors in AV1-AV4, and VA1 when they returned from their walk, there was a preponderance of the evidence that the SP gave and allowed AV1-AV6, and VA1-VA3 to use his/her and/or their own vape/carts that contained marijuana and/or nicotine which was not accidental or therapeutic conduct.

There was no information provided that AV1-AV6, and VA1-VA3 were harmed. However, each was under 21 years old and therefore, it was illegal for a person to give marijuana and/or nicotine to each and encouraged each to participate in actions that were illegal. In addition, AV4’s-AV6’s, VA2’s, and VA3’s plans each stated that they were at either a medium or high risk for substance use/abuse and VA3 had a history of substance use. Therefore, there was a preponderance of the evidence that the SP allowing the youth to access and consume marijuana and/or nicotine was a failure to supply AV1-AV6 with necessary care; a failure protect AV1-AV6 from conditions or actions that seriously endangered his/her physical or mental health when reasonably able to do so; and a failure to supply VA1-VA3 with care that was reasonable and necessary to their physical and mental health and safety.

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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult’s physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct).

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 responsible for the care and supervision of AV1-AV6 and VA1-VA3 and was trained on the facility’s Drug Free Workplace policy, the Reporting of Maltreatment of Minors Act, and the Report of Maltreatment of Vulnerable Adult Act prior to the incident. The SP was responsible for maltreatment of AV1-AV6 and VA1-VA3.

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 was recurring maltreatment because the SP provided THC and/or nicotine to nine youth (AV1-AV6 and VA1-VA3) on more than one occasion.

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 policies and procedures were adequate but not followed. The SP no longer worked at the facility, therefore, there was no need for additional staff training or corrective action.

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

The SP was notified that s/he was responsible for recurring maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.

The facility is licensed by the Minnesota Department of Corrections. A copy of this report was forwarded to them for their review of possible licensing violations.

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: February 20, 2024

raw_content:
February 20, 2024

Suzette Mallum

North Homes, Inc

1815 River Road

Grand Rapids, MN 55744

License Number: 1056074 (Boys Program)

1028358 (TNT)

CORRECTION ORDER

Dear Suzette Mallum,

On December 11, 2023, certification reviews of North Homes Boys program, located at 1815 River Road, Grand Rapids, MN, 55744, and North Homes Boys TNT, located at 916 NW 20th Drive, Grand Rapids, MN, 55744 were conducted to determine compliance with state and federal laws and rules governing the provision of The Family First Prevention Services Act under Minnesota Statues 245A.25. As a result of this certification review a Correction Order is being issued.

A. Reason for Correction Order

Pursuant to Minnesota Statutes, section 245A.25, subdivision 8, 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 certification review. Corrective action for each violation is required by Minnesota Statutes, section 245A.25 and is hereby ordered by the Commissioner of Human Services.

Policies and Practices

1. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraphs (f) and (g).

Violation: The license holder’s policies and practices of trauma-informed care did not meet requirements in the following ways:

a. The program’s designated spaces available to youth for engaging in sensory and self-soothing activities were not described in policy;

b. The program staff did not ensure the designated spaces were available to the youth to use when needed; and

c. Policies did not include that the program prohibits the use of aversive consequences for a youth’s violation of program rules or for any other reason.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure trauma-informed care policies and practices meet all applicable requirements. Within 30 days receipt of this order, submit revised policies on trauma-informed care, as identified above, to demonstrate compliance.

2. Citation: Minnesota Statutes, section 245A.25, subdivision 4, paragraphs (b), (f) through (h), and (j).

Violation: The license holder’s service delivery plan did not meet requirements. The program’s service delivery plan did not include and describe how the license holder:

a. Collaborates with the responsible social services agency and other appropriate parties to implement the youth’s out of home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment;

b. Facilitates the participation of a youth’s family members in the youth’s treatment program;

c. Contacts and facilitates outreach to each youth’s family members, including the youth’s siblings, and documenting the outreach in the youth’s file, including the contact method and each family member’s contact information; and

d. Documents in the youth’s file how the program integrates family members into the treatment process, including after the youth’s discharge, and how the program maintains the youth’s connections to the youth’s siblings.

Correction Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the program’s service delivery plan meets all applicable requirements. Within 30 days receipt of this order, submit a service delivery plan that meets requirements to demonstrate compliance.

Personnel Files

Personnel files reviewed are identified in the following manner:

· Personnel files numbered 1 through 5: Boys Program and TNT

3. Citation: Minnesota Statutes, section 245A.25, subdivision 3, paragraph (h).

Violation: Five of five personnel files reviewed for requirements governing training did not meet requirements in the following ways:

a. There was no documentation to demonstrate that prior to direct contact with a youth, a staff was oriented to:

1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel files numbered 1 through 3); and

2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 through 5); and

b. There was no documentation to demonstrate staff were trained annually to:

1) Concepts of trauma informed care and how to provide services according to these concepts in calendar year 2022 (personnel file numbered 1); and

2) Impacts of culture, race, gender, and sexual orientation on an individual youth’s behavioral health and experiences of trauma in calendar year 2022 (personnel files numbered 1 and 5).

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

Youth Files

Youth files reviewed are identified in the following manner:

· TNT: Youth files numbered 1 and 2

· Boys Program: Youth files numbered 3 through 5

4. Citation: Minnesota Statues, section 245A.25, subdivision 3, paragraphs (c) through (e).

Violation: Five of five youth files reviewed for requirements governing trauma-informed care did not meet requirements. Documentation did not demonstrate:

a. Whether the youth participated in reviewing and developing their individual treatment or service plan (youth files 1 and 5);

b. Whether the license holder adjusted services for the youth to address any additional needs of the youth (youth files numbered 1 through 3);

c. If an assessment was completed to determine if the youth was in need of trauma-specific treatment interventions (youth files numbered 1 through 5);

d. How the license holder recognized the impact of trauma on the youth when determining the youth’s service needs and providing services to the youth (youth files numbered 1 through 5); and

e. In the youth’s treatment plan, how the program would provide trauma-specific treatment interventions to the youth to target the youth’s specific trauma-related symptoms (youth files numbered 1 through 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the provision of trauma-informed services meet all appliable requirements.

5. Citation: Minnesota Statues, section 245A.25, subdivision 4, paragraphs (b), (c), and (f) through (i).

Violation: Five of five youth files reviewed for requirements governing services in qualified residential treatment programs did not meet requirements. Documentation did not demonstrate the license holder:

a. Collaborated with the responsible social services agency and other appropriate parties to implement the youth’s out-of-home placement plan and the youth’s short-term and long-term mental health and behavioral health goals in the assessment (youth files numbered 1, 2, and 3);

b. Completed treatment plan reviews for July 2023 (youth file numbered 2) and February, March, April, and June 2022, and January and March 2023 (youth file numbered 5);

c. Facilitated the participation of a youth’s family members in the youth’s treatment program that was consistent with the youth’s best interests and according to the youth’s out-of-home placement plan (youth files numbered 2 through 5);

d. Contacted and facilitated outreach to each youth’s family members, including the youth’s siblings, and documented the contact method and contact’s information in the youth’s file (youth files numbered 1 through 5);

e. Maintained a record of contact information for all known biological family members and fictive kin of the youth (youth files numbered 1 through 5);

f. Integrated family members into the youth’s treatment process, including after the youth’s discharge from the program, and the youth’s connections to their siblings (youth files 1 through 5);

g. Provided discharge planning and family-based aftercare support for at least six months after the youth’s discharge from the program (youth files 3 through 5); and

h. Ensured monthly contact with the youth and the youth’s caregivers to promote the youth’s engagement in aftercare services and regular evaluation of the family’s needs (youth files 3 through 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure services of a qualified residential treatment program meet all appliable requirements.

If you fail to correct the violations specified in the Correction Order within the prescribed timelines the Commissioner may rescind certification pursuant to Minnesota Statutes, section 245A.25, subdivision 9.

Submissions required as part of a corrective action ordered must be sent to Tina Christensen

1. By secure email to: tina.christensen@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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 Tina Christensen, Human Services Licensor at 651-431-6610, as soon as possible.

Tina Christensen, 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/


facility_name: North Homes Cottage

raw_content:
August 25, 2025

Heidi Seaton, Authorized Agent

North Homes, Inc

303 SE 1st St

Grand rapids, MN, 55744

License Numbers: 1010657 (CRF – Itaskin Treatment Center)

1047010 (CRF – North Homes Cottage)

CORRECTION ORDER

Dear Heidi Seaton:

On June 9 through 12, 2025, DHS licensors conducted a licensing review of Itaskin Treatment Center, located at 1880 River Rd, Grand Rapids, MN, 55744, and North Homes Cottage, located at 1920 SE River Rd, Grand Rapids, MN, 55744. This review was conducted to determine compliance with state and federal laws governing children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0220, shelter care services for children under Minnesota Rules, part 2960.0510 through 2960.0530, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0700, restrictive techniques standards under Minnesota Rules, part 2960.0710, and qualified residential treatment programs 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.

Throughout this order, the licensed programs will be referenced as follows:

· Itaskin Treatment Center (ITC);

· North Homes Cottage (NHC); and

· When citations are specific to both licensed programs (ALL).

Procedures

1. Violation: The license holder’s grievance procedure did not meet requirements (ALL). The procedure did not require that a person filing a grievance would receive a response within five days. The procedure included multiple steps by which a grievance would be reviewed, and the first step did not include a timeframe.

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 the grievance procedure meets all applicable requirements. Within 30 days receipt of this order, submit a revised grievance procedure that demonstrates compliance.

Practices

2. Violation: The license holder’s program evaluation for 2023 and 2024 did not meet requirements in the following ways (ALL):

a. The evaluation of strengths and weaknesses did not include the following required performance indicators:

i. Accidents; and

ii. Information from Minnesota Rules, part 2960.0060, subparts 1 and 2, regarding the program’s outcome measures; and

b. Documentation did not include an evaluation of the program’s strengths and weaknesses based on results of resident and family satisfaction surveys.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure program evaluations include all required components.

3. Violation: Two of two weeks of documentation reviewed for requirements governing clinical supervision did not meet requirements. All staff providing program services did not receive weekly face-to-face clinical supervision:

a. For the treatment week beginning June 1, 2025: Three staff persons (NHC); and One staff person (ITC); and

b. For the treatment week beginning December 15, 2025: One staff person (ALL).

[Rule/Statute] Violated: Minnesota Rules, part 2960.0630, subpart 2

Repeat Violation: In a Correction Order that DHS issued on December 3, 2021, you were previously found in violation of this same rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of clinical supervision meets all applicable requirements.

Resident Files

Resident files reviewed are identified in the following manner:

o Resident files numbered 1 through 5, and 7 (NHC);

o Resident files numbered 2 through 4, 6 and 7 (ITC).

4. Violation: One of six resident files reviewed for requirements governing the license holder’s ability to meet residents' needs did not meet requirements (resident file numbered 2). There was no documentation to demonstrate the license holder determined the program could meet the resident’s cultural, emotional, educational, mental health and physical needs.

Rule Violated: Minnesota Rules, part 2960.0160, subpart 2, item C

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

5. Violation: Six of seven resident files reviewed for resident screenings did not meet requirements in the following ways:

a. For a shelter admission, there was no documentation to demonstrate a health screening was arranged for within 24 hours of admission (resident file numbered 2);

b. The health screening did not include all required components. Documentation did not identify the resident’s most recent clinic name, address, and telephone number (resident files numbered 1 through 5 and 7); and

c. The cultural screening was not completed, it was blank (resident file numbered 7).

Rule Violated: Minnesota Rules, parts 2960.0520, subpart 2, item B, and 2960.0070, subpart 5, items B and C.

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

6. Violation: Three of seven resident files reviewed for requirements governing admission procedures did not meet requirements. There was no documentation to demonstrate the license holder provided the following required information:

a. The facility’s rules and details of the due process system used in the facility, verbally and in writing to the resident (resident files numbered 2 and 5);

b. A written copy of the resident’s basic rights information (resident files numbered 2 and 5);

c. That information on the resident’s basic rights is available, to the resident’s parent, guardian or custodian (resident files numbered 2, 4, and 5); and

d. How to contact the appropriate state-appointed ombudsman (resident files numbered 2 and 5); and

e. A copy of facility rules (resident file numbered 2).

Rule Violated: Minnesota Rules, parts 2960.0160, subpart 4; 2960.0080, subpart 4; and 2960.0050, subpart 3, items A, B, and E

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

7. Violation: Six of six resident files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements in the following ways:

a. The ITP was not completed within 10 working days of admission, it was completed late (resident files numbered 1 and 4);

b. The ITP did not include a schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 4, 6 and 7);

c. The ITP did not include all goals and objectives of treatment (resident file numbered 7). Documentation in the resident file indicated the license holder provided family therapy, and there was no related goal or objective in the ITP; and

d. The ITP did not include the use of all psychotropic medications (resident files numbered 2 and 4).

Rule Violated: Minnesota Rules, part 2960.0600, item A and part 2960.0620, subpart 1, item A

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

8. Violation: One resident file reviewed for requirements governing family involvement in a qualified residential treatment program (QRTP) did not meet requirements (resident file numbered 6). There was no documentation to demonstrate how the program maintains the youth’s connections to their siblings.

Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (h)

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

9. Violation: Four of four resident files reviewed for requirements governing the review of the resident’s case and treatment plans did not meet requirements (resident files numbered 2, 3, 6 and 7). There was no documentation to demonstrate the plan was reviewed on a monthly basis.

Rule Violated: Minnesota Rules, part 2960.0180, subpart 2, item B

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure documentation of the treatment plan review meets all applicable requirements. Within 30 days receipt of this order, submit documentation for one resident demonstrating a monthly review took place.

10. Violation: Three of five resident files reviewed for requirements governing psychotropic medications did not meet requirements. There was no documentation to demonstrate the following was completed as required:

a. Monitoring for side effects at least weekly for the first six weeks after a resident begins taking a new psychotropic medication (resident files numbered 3, 4 and 7); and

b. Monitoring for tardive dyskinesia at least every three months if the resident is prescribed antipsychotic medication (resident files numbered 3 and 7).

Rule Violated: Minnesota Rules, part 2960.0620, subparts 2 and 3

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the monitoring of the use of psychotropic medication meets all applicable requirements.

11. Violation: One resident file reviewed for requirements governing time-out did not meet requirements (resident file numbered 7). Discharge documentation identified the use of time-out occurred on November 30, 2024, and there was no documentation of the time-out that included the factors or circumstances which caused the need for the use of time-out, the resident’s response, their ability to de-escalate during the time-out or their ability to maintain acceptable behavior after the time-out.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the documentation of the use of time-out meets all applicable requirements.

12. Violation: One of three resident files reviewed for requirements governing restrictive procedures did not meet requirements (resident file numbered 7). The license holder documented the use of physical holds in a “Restrictive Procedure Report”. Documentation in the resident file referenced multiple instances of physical holds and physical escorts between June 24, 2024, and August 2, 2024, and there were no corresponding “Restrictive Procedure Reports” in the resident file.

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, item K.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure

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

a. The administrative review was not completed within three working days for the following instances of restrictive procedures:

i. March 31 and April 6, 2025 (resident file numbered 5); and

ii. August 29, October 28, November 26 and 27, 2024 (resident file numbered 7); and

b. The administrative review did not include whether the rule standards governing the use of restrictive procedures were met (resident files numbered 1, 3 through 5, and 7).

Rule Violated: Minnesota Rules, part 2960.0710, subpart 10, item C.

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

14. Violation: Six of six resident files reviewed for requirements governing transition services plans did not meet requirements (resident files numbered 1, 2, and 4 through 7). Documentation did not demonstrate a copy of the plan was given to the resident.

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

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

15. Violation: Two of three resident files reviewed for requirements governing the provision of aftercare in a qualified residential treatment program (QRTP) did not meet requirements (resident files numbered 2 and 7). There was no documentation to demonstrate the license holder provided discharge planning and family-based aftercare support to each youth for at least six months after discharge.

Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (i).

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of aftercare services meets all applicable requirements.

Personnel Files

Personnel files are identified as follows:

o Personnel files numbered 1 through 15 (ALL)

16. Violation: Two of six personnel files reviewed for requirements governing documentation of staff qualifications did not meet requirements (personnel files numbered 3 and 4). The personnel file did not include records showing that the staff person’s professional licensure is current.

Rule Violated: Minnesota Rules, part 2960.0150, subpart 2

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

17. Violation: Nine of nine personnel files reviewed for requirements governing annual training did not meet requirements in the following ways:

a. There was no documentation to demonstrate the staff person received annual training on the program abuse prevention plan (PAPP) in 2024 (personnel files numbered 1, 3, 4, 6, 7, and 9 through 11); and

b. There was no documentation to demonstrate the license holder reviewed the emergency plan with the staff person at least once every six months (personnel file numbered 12).

Rule and Statute Violated: Minnesota Statutes, section 245A.65, subdivision 3, and Minnesota Rules, part 2960.0080, subpart 14

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision and documentation of annual training meets all applicable requirements. Within 30 days receipt of this order, submit documentation demonstrating all staff have received training on the PAPP.

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 Alyssa.nelson@state.mn.us or by mail:

Commissioner, Department of Human Services

ATTN: Alyssa Nelson

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 in writing. Your request must:

1. Specify the parts of the correction order that are alleged to be in error;

2. Explain why they are in error; and

3. Include documentation to support the allegation of error.

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

Legal authority for this licensing action

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 651-431-6259 or at katie.a.leuer@state.mn.us

Sincerely,

Katie Leuer, Unit Supervisor

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/


facility_name: Northwestern Minnesota Juvenile 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: 202601692

Date Issued: April 6, 2026

Name and Address of Facility Investigated:

Northwestern Minnesota Juvenile Center
1231 Fifth Street NW
Bemidji, MN 56619

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

License Number and Program Type:

1036937-CRF (Children’s Residential Facility/Department of Corrections)

Investigator(s):

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) pushed an alleged victim (AV) backwards into the AV’s bedroom and attempted to forcefully close the bedroom door, but the door bounced open. The SP then “slammed” the door a second time and it latched. The AV’s hand was caught between the door and its frame, and s/he sustained injuries to his/her hand.

Date of Incident(s): February 17, 2026

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 March 4, 2026; from documentation at the facility and the AV’s medical records; and through interviews conducted with facility staff persons (P1, P2, and P3), the AV, and the AV’s guardian (G). Two letters, one certified, were sent to the SP requesting an interview with this investigator, but the SP did not respond to the letters or attempts to contact him/her by phone or email.

The facility was a juvenile detention facility that focused on providing individualized services to youth to meet their specific needs. At the time/date of the incident, the AV resided in the secure detention unit at the facility which was for youth 10 to 20 years of age. There was an educational program on site and youth who resided in the secure detention unit had individual cells/bedrooms with metal doors that latched into metal frames when the doors closed. The doors did not have doorknobs or handles on the inside of the bedroom but there were slots in the doors that youth inside the bedrooms could put their fingers in to push the door open. There were narrow windows with sliding covers set into the doors through which staff persons could see the youth inside the bedrooms. The facility had a video recording system that recorded common areas of the facility, but the system did not record sound.

Facility documentation showed that the AV was diagnosed with asthma and sometimes had behaviors that caused other youth in the unit to become upset. Staff persons documented that the AV treated them with disrespect and provided inaccurate information to them. However, the AV was outgoing and liked listening to music.

Interviews with this investigator, the AV’s medical records, facility documentation, video recordings from the facility, and the facility’s Internal Review, provided the following:

· Information was consistent that on February 17, 2026, the AV’s hand was injured at the facility, and the AV was evaluated at the emergency department of a hospital. An x-ray taken at the hospital showed that the AV had an open displaced fracture of his/her right index finger, a laceration of the right index finger without foreign body or damage to the nail, and a laceration of the right little finger without foreign body or damage to the nail. The AV was prescribed an antibiotic, the lacerations were closed with stitches, and the AV was referred to an orthopedic/sports medicine center for additional care.

· The AV said that on the date of the incident, s/he was upset because s/he had to reside at the facility. The AV stood in his/her bedroom doorway talking with an unspecified staff person when s/he felt that the SP interrupted his/her conversation. The AV told the SP that s/he was not talking to him/her. The SP walked quickly toward the AV, who continued to stand in the doorway of his/her bedroom, then grabbed the door and slammed it. The AV’s hand was between the door and the door frame and was caught between them which prevented the door from latching. The AV removed his/her hand from the doorway, and the SP slammed the door again. The AV stated that his/her hand was “busted open” and s/he thought s/he might faint. There was blood dripping from the AV’s hand and s/he saw some of the bones in his/her hand. Two or three minutes later, P1 checked on the AV in his/her bedroom, realized that the AV was injured, and called other staff persons for assistance. P1 gave the AV paper towels to hold against his/her hand, and a staff person who was not involved in the incident drove the AV to the emergency department of the hospital.

· The video recording from the facility showed that at 9:36:07 a.m., on the date of the incident, the AV opened the door to his/her bedroom, stood in the doorway, and spoke to the SP and P1, who were seated at a desk in the common area of the unit, with their backs toward the AV. The SP turned toward the AV with the SP’s back to the camera, shrugged, appeared to talk with the AV, shrugged his/her shoulders, and then stood and walked toward the AV at 9:36:40 a.m., who continued to stand in his/her bedroom doorway. P1 stood and took a couple of steps toward the AV’s bedroom but could not see into the bedroom from where s/he stood. At 9:36:47 a.m., the SP pushed the AV near the AV’s chest with his/her right hand while using his/her left to simultaneously close the AV’s bedroom door. The door did not close and latch, and the SP closed the door again with both hands at 9:36:50 a.m., then returned to the desk in the common room.

· The SP and P1 talked and worked on their laptops, then at 9:38:51 a.m., P1 stood, walked to the AV’s bedroom, opened the sliding window cover which was closed, then looked through the window and took the walkie talkie from his/her waist at 9:38:56 a.m. to call for assistance. P1 then closed the sliding window cover and walked away from the AV’s bedroom toward the desk where the SP sat. P1 and the SP talked and went to a cabinet in the common area where they put on blue nitrile/latex gloves. Several other staff persons, including P2 who was a supervisory staff person, entered the common area, put on gloves, and entered the AV’s bedroom at 9:39:51 a.m. The video recording system did not show the interior of the AV’s bedroom. The SP did not enter the bedroom and stood near the desk in the common area, then at 9:42:16 a.m. the SP moved to the left of the view shown by the camera and stood behind the desk. At 9:45:18 a.m., staff persons assisted the AV to put on his/her shoes, and at 9:46:28 a.m., the AV and a staff person left the common area of the unit in which at AV resided to go to the hospital.

· P1 said that s/he witnessed the incident and assisted the AV after s/he discovered that the AV’s hand was injured. The incident started when the AV stood in the doorway of his/her bedroom and “yelled” at the SP and P1 about the educational program at the facility. P1 and the SP redirected the AV to remain in his/her bedroom and the AV replied to the SP, “I’m not talking to you, bitch.” The SP then went to the AV’s bedroom, pushed the AV into the bedroom, and closed the door. The door did not close, and the SP closed it again, then returned to sit at the desk. P1 did not think that the SP was upset or angry when the incident occurred.

· After a minute or two, P1 heard the AV hitting the bedroom door, yelling, and “swearing” so s/he checked on the AV and discovered that the AV’s hand was injured. P1 immediately called for help and multiple staff persons quickly came to the unit. The account of the remainder of the incident provided by P1 was largely consistent with the recording from the video recording system. P1 said that s/he did not follow the facility’s policies and procedures and that s/he should have asked the SP to leave the unit when s/he pushed the AV and forcefully closed the AV’s bedroom door. P1 said that s/he should have checked on the AV quicker and s/he would have checked on the AV sooner if s/he had realized that the AV was injured.

· P2 did not have firsthand knowledge of the actions that led to the incident, but s/he reviewed the video recording of it and talked with P1 and the SP regarding their actions during the incident. The SP’s actions were inconsistent with the facility’s policies and procedures, and staff persons were not permitted to push/shove youth. The SP should not have closed the bedroom door without making sure that the doorway was clear. After the incident occurred, staff persons and P2 focused on getting the AV to the hospital as soon as possible.

· The AV’s medical records showed that the AV’s injuries were initially treated on February 17, 2026, at the emergency department of the hospital. The lacerations were stitched closed and the AV was prescribed an antibiotic. The next day, the AV had an appointment with an orthopedic physician who determined that the AV required surgery to repair the injuries to his/her right hand. The physician documented that s/he felt the AV would benefit from reduction of an articular condyle fragment of the middle phalanx at the distal interphalangeal joint with pinning and explained that the AV would experience stiffness in that joint, with possible further deterioration of the joint, making future surgeries necessary. On February 19, 2026, the AV had surgery to repair the injuries to his/her hand and then was discharged back to the facility with instructions to attend follow up appointments and seek additional medical care if needed.

· The SP did not respond to this investigator’s attempts to contact him/her and no information from the SP was included in the facility’s Internal Review.

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

Conclusion:

A. Maltreatment:

Information was consistent that on February 17, 2026, the AV’s hand was injured at the facility when the SP closed the door to the AV’s bedroom and caught the AV’s hand between the door and the door frame.

A video recording of the incident from the facility and an account of the incident from P1 who witnessed the incident showed that the AV stood in his/her bedroom doorway and spoke with the SP and P1 who were sitting at a desk in the unit common area. The SP went to the AV’s bedroom, pushed the AV’s chest causing the AV to step backward into his/her bedroom, and the SP forcefully closed the door onto the AV’s hand. The SP returned to the desk, and after a couple of minutes, P1 checked on the AV and observed that the AV’s hand was injured. P1 called for assistance and multiple staff persons came to the unit.

The AV was taken to the emergency department of the hospital where s/he was evaluated and diagnosed with an open displaced fracture and laceration of his/her right index finger and a laceration of the right little finger. The AV was prescribed an antibiotic, the lacerations were stitched closed, and on February 19, 2026, s/he had surgery on his/her hand to repair the injuries sustained when the door was closed on his/her hand. After surgery, the AV was discharged back to the facility with follow up appointments scheduled.

P2 reviewed the video recording of the incident and said that the SP’s actions were inconsistent with the facility’s policies and procedures. Staff persons were not permitted to push or shove youth and the SP should not have closed the bedroom door without ensuring that the doorway was clear.

Given that the video recording showed the SP push the AV into his/her bedroom and close the door on the AV’s hand, that the AV required the care of a physician and surgery to repair the injuries to his/her hand, and that P2 said that SP’s actions were inconsistent with the facility’s policies and procedures, there was a preponderance of the evidence that the AV sustained physical injuries by means other than accidental.

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.

The video recording showed the SP push the AV into his/her bedroom and close the door on his/her hand. 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 abuse for which the SP was responsible was serious because the AV sustained injuries including skin lacerations, tissue damage, and fractures as a result of the incident. The abuse for which the SP was responsible was not recurring since it was a single 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 completed an Internal Review which determined that its policies and procedures were adequate but were not followed. The SP was immediately placed on leave after the incident and at the time this report was written, the SP was no longer employed at the facility. P1 was initially placed on leave after the incident then suspended for three days for failure to follow the facility’s Emergency Plan and Procedures Policy. P1 was retrained and returned to work at the facility. The incident was not similar to past incidents.

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.

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