report_date: December 29, 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: 202405433

Date Issued: December 29, 2025

Name and Address of Facility Investigated:

Northwestern Minnesota Juvenile Center
1231 Fifth St. NW
Bemidji, MN 56619

Disposition: Maltreatment determined as to neglect of an alleged victim by the facility.

License Number and Program Type:

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

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 an alleged victim (AV) was kept in an isolation cell for over five months with lights on and no exercise or sunlight, where the AV engaged in acts of self-harm with no meaningful medical treatment or mental health treatment.

Date of Incident(s): January to July 2024.

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on June 27, 2024; from documentation at the facility; and through seven interviews conducted with the AV, two facility managers (P1-P2), the AV’s facility case manager (CM), the AV’s guardian (G), and two professionals who worked with the VA but were not employed by the facility; a legal professional (LP) and a mental health professional (M). Two staff persons (P4 and P5) did not respond to attempts to request interviews.

The AV was diagnosed with attention deficit hyperactivity disorder (ADHD), fetal alcohol syndrome, schizophrenia, and intermittent explosive disorder. The AV was placed at the facility by the court pending judicial proceedings.

The facility was a children’s residential facility that provided treatment, training, and detention for juveniles and was licensed by the Minnesota Department of Corrections (DOC). The secure areas of the facility in which the AV was placed consisted of two sections. The first section was the general population area with multiple individual cell units and a main common area in the center. All cells had windows looking out into the common area. The second section was known as the secure perimeter, an area where the facility had individual cells with no common area and no visibility outside of the cells. Within the secure perimeter, the AV was kept in cell 17, a locked cell located between the control room and a supervisor’s office; it had a window that the control room could look down into and a live camera feed into the control room. It was used for residents demonstrating violent behavior or those causing a disruption in the unit. The cell had overhead lights that remained on 24 hours a day.

Per the DOC’s memo lnterim Guidance on the lmminent Approaching lsolation as Discipline Ban, issued on November 29, 2023; administrative separation was “staff-initiated separation used when a facility was looking into a resident’s serious behavioral offense, evaluating, or investigating criminal activity, or placing a resident in individualized modified environment, and determining next steps and requiring administrative approval.” The DOC’s ban on using isolation as discipline became effective on January 1, 2024. The guidance noted that administrative separation required administrative approval and daily documentation why it was necessary and why other alternatives were not available or unsuccessful. It required the creation of an Individual Modified Plan (IMP) to address daily programming.

On January 3, 2024, the facility issued a document regarding Policy Approval for Safety-Based Separation to Replace Disciplinary Room Time, which required approval from the facility superintendent and daily documentation on the need for administrative separation and why other alternatives were not available or unsuccessful. At the facility, residents could be placed in administrative separation within their cells in the general population area or within the secure perimeter area. Residents placed in administrative separation were not allowed outside their cells unless it was for services required by law such as healthcare, education, recreational and leisure time. However, access to those services could be denied due to an active safety risk and staff persons had to document which services were denied and the safety risk that made the provision of that service unsafe. Residents not on administrative separation would program with the rest of the residents in the pod (unit). On the day this investigator visited the facility, cells in the general population area were open and residents moved freely about.

The AV was admitted to the facility on January 10, 2024, and placed in cell 3 and then moved to cell 7 both which were in the general population area of the secure wing. Cells in the general population area had narrow vertical windows allowing residents to look out into the common area. The AV was first placed in administrative separation on January 16, 2024, within the general population area of the facility. Staff persons at the facility filled out daily logs which documented the times that the AV received meals and snacks, medications, schoolwork, showers, recreation, leisure time, phone calls, and visits. For each of these items, staff persons had to initial their recordings on the daily logs.

The facility provided an undated document, Administrative Separation Approval and Review, regarding the required daily approval of the AV's placement on administrative separation. However, it only documented the daily administrative approval from January 17-26, 20242024; only 10 days out of the 182 days that the AV was placed on administrative separation. During that brief time period, the documented noted the reasons for the continued need for the AV to be on administrative separation included threats against staff persons and medication refusal. An undated note from P1 stated, "[AV] will continue on Administrative Separation and will have [her/his] IMP updated daily, or as appropriate." The document did not contain any information on why other alternatives were not available or unsuccessful or any rationale that taking medication was a prerequisite for the AV to have daily programming. The document noted that the AV spent 182 days on administrative separation.

The following information was obtained from the facility’s documentation regarding administrative separation of the AV from January 16 through July 14, 2024:

· January 2024: The AV was placed in administrative separation from January 16-31, 2024, within the general population area of the facility. The AV had numerous phone calls and visits, received recreational and leisure time, and was allotted time for showering. On a number of occasions, documentation showed that the AV refused recreation and leisure time. On January 19, 2024, the AV was denied recreation and leisure time, and showering time because the AV had made verbal threats toward staff persons. On January 22, 2024, the AV was denied recreation and leisure time because s/he was having behaviors at the time staff persons could offer recreation time. On January 23, 2024, a staff person wrote “unable to accommodate” for recreation time. On January 31, 2024, a staff person wrote "could not due to not having enough time," for recreation time. On four occasions throughout the month of January 2024, the AV refused his/her medications. Those dates were not the same dates on which the AV was denied programing such as recreation or leisure time by the facility.

· February 2024: From February 1-10, 2024, the AV was on administrative separation within the general population area. On February 11, 2024, the AV assaulted a staff person and was moved to cell 17 in the secure perimeter of the facility where s/he remained on administrative separation in the secure perimeter for the rest of the month. The AV refused to take his/her medications on numerous occasions. On some of the same dates, the AV was denied recreation and leisure time and sometimes shower time. According to notes in the IMP forms written by staff persons, the reasons given were due to the AV’s behavior and not because the AV had refused to take some or all of his/her daily medications. On February 28, 2024, the IMP notes that the AV was placed in a physical hold after taking noon medications but a reason for the hold was not in the IMP.

· March 2024: The AV spent the whole month of March in cell 17 in the secure perimeter. The AV refused various medications on March 4, 6, 9, 12, and 13, 2024. On March 4, 2024, the AV was denied recreation due to threatening staff persons. On March 6, 2024, the VA was denied a shower when threatening staff persons. On March 8, 2024, the AV was only given 20 minutes of recreation time with no reason given as to why. On various dates throughout March 2024, staff persons did not document whether the AV received recreation and leisure time or showers. On March 14, 2024, the IMP notes stated that the AV kicked the sink and repeatedly punched the wall until her/his hand was bloody, and which occurred again on March 31, 2024. On March 20, 2024, the IMP notes stated that the AV knocked on the control window, and punched the wall demanding free time, after the AV had received recreation and leisure time that day.

· April 2024: Except for two days, the AV was in the secure perimeter area of the facility. On April 5, 2024, the AV was moved from cell 17 in the secure perimeter area back to cell 7 in the general population area but remained on administrative separation. On April 7, 2024, the AV was returned to cell 17 after assaulting a staff person. From April 7 to 9, 2024, the AV refused some or all of his/her medications. On April 8 and 9, 2024, the AV was denied all programming; the IMP forms noted “refusing [medications] is refusing to program.” For the following three days, the AV took his/her medications, but staff persons did not document any programming for the AV. With the exception of two days, from April 15 through 30, 2024, the AV refused some or all medications; on ten of those days, the AV was denied recreation and leisure time because s/he refused medications. On April 16, 2024, a staff person noted that the AV was awake at 5:55 a.m., biting and scratching her/his arms until they bled. On April 18, 2024, the AV attempted to assault a staff person and was placed in a WRAP (a restraint system, used to restrain a resident in an upright and seated position, designed to protect residents and staff persons by reducing risk of injury); the IMP did not provide a reason for the use of the physical hold, but notes that the AV stretched out the WRAP. The following day, the AV had her/his shoulder examined by a medical professional. (Note: The AV was diagnosed with a strained shoulder and prescribed over the counter medication to be taken as needed.) On April 20, 2024, it was noted that the AV reopened the wounds on her/his arm. As in previous months, on a number of days, staff persons did not document any programing for the AV.

· May 2024: The AV spent the whole month of May 2024, in administrative separation in cell 17 in the secure perimeter area of the facility. From May 1-4, 2024, the AV refused some of her/his medications and was denied all programming except for showers on May 4 and 5, 2024. On May 6, 2024, the AV again refused some medication but was given recreation and leisure time. From May 5 to 12, 2024, and May 18 to 22, 2024, documentation on the IMP forms was scarce. On May 14, 2024, staff persons noted that the AV picked at scabs on her/his arm. On May 19, 24, and 27, 2024, the AV was observed punching the wall, door and/or control window, and “practicing eye gouging” on May 24, 2024.

· June 2024: The AV remained in cell 17 from June 1 to 6, 2024, when the AV was then moved to cell 5, in the general population area still in administrative separation, after a court appearance. Throughout the month of June 2024, documentation on medication administration was scarce. On numerous days the IMP form did not contain a spot for recording what medications were taken or refused and staff persons did not document whether the AV had recreation or leisure. On June 4, 2024, the AV was denied recreation and leisure time and denied shower time due to behavior issues. On June 12, 2024, the AV did not finish recreation time, shower time, and a phone call due to “unpredictable behavior.” On June 16, 2024, the IMP notes stated that the AV did not get recreation or leisure time due to “aggressive behavior,” the following day the AV received solo programming due to behaviors the prior day. On June 24, 2024, the AV was denied leisure and afternoon recreation due to behaviors.

· July 2024: From July 1 to 14, 2024, the AV remained in the general population cell and on administrative separation. Staff persons did not document any medication administration on the IMP forms. The facility did not provide an IMP form for July 2, 2024. On numerous days, staff persons did not document recreation, leisure, and/or shower time.

Note: When the AV engaged in acts of self-harm, the AV was provided with basic medical care.

The AV provided the following information:

· The AV stated that while s/he was in cell 17 in the secure perimeter, the AV felt like s/he was “dying” in large part because the lights were on constantly, it messed with her/his mind, and s/he went “crazy” because there was a lack of human interaction. The AV stated that being in cell 17 messed with her/his mind to the point that the AV believed that staff persons were “tripping” her/his medications so many times the AV would refuse medications. The AV also believed that s/he heard voices of other residents wanting to hurt him/her. The AV told a judge at a court hearing that s/he did not want to go the general population area.

· The AV recalled being in cell 17 and having to move the mattress to the floor because the lights were “so bright.” That same day staff persons came in and placed the AV in a WRAP. The AV stated that staff persons used excessive force when applying restraints and believed that staff persons injured her/his shoulder in the process of restraining her/him prior to being placed in the WRAP.

· The AV pointed out that s/he had been in a number of other juvenile centers and none of them had cells like cell 17. The AV further stated that no kid should have to be placed in a cell like cell 17.

The M provided the following information:

· The M began working with the AV in February of 2024 due to aggressive/assaultive behavior and acts of self-harm such as biting her/his forearm. The AV had reported having delusions and paranoia that people were out to get her/him but then would say, “I don’t really think that is happening.”

· At first the AV was easily agitated, paranoid, and his/her stream of thoughts went from topic to topic. The M was aware that the AV was kept in cell 17 and the room was very well lit. The AV told the M that s/he had a hard time sleeping at night and would sleep during the day.

· The M noted that being in a small area with lights constantly on, and “being by yourself more hours of the day than not,” could exacerbate the AV’s irritability, agitation, and aggressive behavior.

· The M stated that s/he talked to facility management, on an unspecified date, about the effects of being in cell 17 had on the AV. Their goal was to move the AV to the main area once the AV’s behavior was less dangerous. The M spoke to management about alternatives to cell 17 but was told there was no other option.

· The M estimated that the AV spent about three and a half to four months in cell 17 but would be let out of the cell 4-5 times a day for various reasons.

· The M was aware that the AV would engage in acts of self-harm; biting her/himself, removing areas of skin on both arms, and picking at scabs which staff persons would clean and bandage. The M also noted that it was reported that the AV would bang her/his head on the wall.

The following information was obtained from the AV’s mental health records regarding visits with the M:

· On February 9, 2024, the M wrote up a temporary prescription, at the request of P2, for four medications that the AV was about to run out of or had run out.

· On February 20, 2024, the G consented to having the M work with the AV. After every visit with the AV, the M would discuss the administrative separation with P1, P2, and the CM. The M discussed with P1, P2, and the CM using a long-acting injectable to help the with AV’s aggressive behavior. The G agreed to proceed, and the new medication was prescribed and ordered and while waiting for approval from the AV’s insurance; an appeal was filed. Other medications changes were made.

· March 22, 2024, the M conducted an initial evaluation with the AV. The AV reported having anger issues and needing help, having difficulty sleeping at night, often sleeping during the day, and feeling tired. The AV also reported having a poor appetite, feeling nervous almost daily, feeling restless, easily becoming annoyed and irritable, but that her/his mood could change quickly and s/he struggled with paying attention, heard voices, and engaged in self-harm.

· On April 5, 2024, the AV reported being placed in more than one physical hold by staff persons due to her/his behavior. The AV stated, "I do not want to hurt anyone. I'm not that kind of person." The M discussed with the G and agreed to starting a new medication, lithium carbonate. The AV continued to report having a poor appetite.

· On April 24, 2024, the AV reported experiencing increased paranoia, hearing voices, and believing others were plotting against the AV. Schizophrenia was added as a diagnosis for the AV. It was noted that the AV’s insurance declined coverage of the long-action injectable. The AV continued reporting having a poor appetite.

· On May 2, 2024, the AV reported continued auditory and visual hallucinations. The AV could not recall being in a catatonic state, standing in one spot for over two hours in her/his cell. The AV reported having a poor appetite. The AV’s long-action injectable Aristada Initio (an antipsychotic used to treat schizophrenia) was started on May 3, 2024, and other medications were discontinued.

· May 8, 2024, after the first dose of Aristada, the AV reported doing better and was reading and eating. At times the AV would get irritable and upset but calmed down with non-physical interventions by staff persons. The AV was reminded that s/he could take lorazepam for anxiety or other strong emotions as needed. Staff persons at the facility reported that the AV had not shown any aggressive behavior after taking the injection.

· May 16, 2024, the AV reported to still having auditory hallucinations, but feeling calmer and less stressed, and having an improved appetite. The AV had become more engaged, read books, and played basketball with staff persons and a social worker.

· May 22, 2024, the AV reported feeling calmer and less stressed since receiving the long-acting injectable and had an improved appetite but still had some auditory hallucinations. The AV reported doing better, had been playing basketball with staff persons and the social worker. Due to insurance coverage, the long-acting injectable was changed from Aristada to Abilify Asimtufii, also a long-acting injectable antipsychotic medication used to treat schizophrenia.

· May 30, 2024, the AV received a shot of Abilify Asimtufii, which was to be administered every two months or sooner if symptoms of agitation, irritability/anger, hallucinations, or other negative symptoms were observed.

· June 6, 2024, the AV reported “doing better,” and was able to stop and think about her/his next actions or words leading to fewer outbursts and less physical aggression. June 13, 2024, the AV reported feeling more in control, becoming less irritated and upset. The AV requested to have melatonin started again due to trouble falling asleep at night. June 20, 2024, the AV reported s/he got upset, threw a tray, and put her/himself in “lockdown.” The AV requested to have melatonin to aid her/him sleep at night. June 26, 2024, the AV reported being called a racial slur by another resident which made the AV mad but the AV reported being able keep her/himself from becoming aggressive and physically acting out.

· July 5, 2024, the AV noted getting more irritated and wanted another shot of the long-acting injectable. The AV discussed an upcoming request for a furlough on July 29, 2024, to see her/his family on her/his birthday. Since receiving the first long-acting injectable, the AV had few instances of demonstrating physical aggression, the AV reported sometimes arguing with staff persons but then listening to them. July 10, 2024, the AV again noted that s/he had been getting more irritated and wanted another shot of the long-acting injectable. The AV was told s/he would have to wait until it was due again, the following week. July 18, 2024, the AV was given another dose of the long-acting injectable. July 24, 2024, the AV reported doing well; managing behavior and was looking forward to a home visit on July 29, 2024.

· August 1, 2024, the AV noted that s/he had four weeks of positive behavior management. The AV remained in the secure unit of the facility but would be programming with youth in the non-secure unit.

P1 provided the following information:

· The AV had previously been housed at the facility numerous times and had a history of aggressive behavior toward staff persons and peers. On January 10, 2024, the facility was informed that the AV would be placed at the facility that same day while awaiting judicial proceedings. P1 was concerned about the AV’s placement at the facility due to the AV’s history at the facility and their available resources but noted that for some youth, the facility was the only option for the courts to place them.

· P1 stated that when a resident was placed on any kind of separation P1 must provide approval. P1 stated that the AV had been in administrative separation on and off since February 2024. The AV did not spend 24 hours a day in separation but was allowed out for hygiene, phone calls/visits, recreation, leisure time, and appointments. If the AV’s behavior did not allow for her/him to be in the common areas, the AV would be served meals in the cell. While in separation, staff persons were required to check in on the AV every 30 minutes.

· On April 18, 2024, the AV was placed in a WRAP because s/he was hiding under a blanket during a check and refused to remove the blanket. When staff persons went in, the AV jumped up and attempted to bite staff. The AV was secured and placed in a WRAP. While in the WRAP, the AV attempted to stretch out the WRAP. The following day the AV was evaluated by a facility nurse and later taken to a medical facility to have her/his shoulder examined; the AV was diagnosed with a muscle strain and was prescribed 400mg of ibuprofen every six to eight hours as needed.

· P1 was not aware of the AV engaging in acts of self-harm while in administrative separation but did note that the AV would pick at a scab on her/his arm. P1 was aware of the AV having auditory hallucinations. The AV had reported hearing others talking and not knowing if it was real or imagined.

· P1 stated, “We are doing everything we can to get [the AV] everything [s/he] needs,” but noted that when the AV first arrived at the facility, they “could not do much with [the AV].” The AV received educational services on a 1:1 basis with the CM because it was too dangerous to have the AV in the classroom. Sometimes P2 would do schoolwork with the AV. P1 stated that the AV was 1:1 throughout February and March 2024, and they tried to get the AV back in the classroom in April 2024, but because the AV was still displaying some aggression, a staff person would sit with the AV in the day room near the entryway of the classroom during some lectures.

· In March of 2024, the AV began to see a mental health provider and received educational services at the facility. In April 2024, the AV started an injectable medication that was changed in May 2024.

· The facility tried multiple times to place the AV back in the general population, the AV had made significant progress but was still a “very dangerous adolescent when not on injectable medications.”

· P1 stated that while in cell 17, the AV would pound on the walls for hours at night, make barking noises for hours, and when staff persons would open the door to provide service, the AV would hide around the corner.

On July 11, 2024, P1 wrote a letter to the DOC Commissioner responding to the maltreatment report. The letter made no mention of the AV being denied programming due to refusing her/his medications.

P2 provided the following information:

· P2 stated that residents at the facility could be denied programming such as recreation and leisure time if the resident was a safety threat to other residents or staff; such behavior would get documented in Chronos (the facility’s documentation system). For residents that were placed in administrative separation, staff persons had to document the residents’ activities on the IMP form which noted the time that a resident was given programming activities along with the staff persons initials. If that was not documented on the form, staff persons would go back and document on the IMP or document in Chronos that it was not documented in the IMP form.

· Residents were required to be given two hours of recreation time per licensing rules. Residents also got recreation time while in school, but that time was not counted as part of the facility’s requirement. When residents were not given the required time, it was to be documented. A resident may be denied programing or have their programming cut short if they were a safety threat to other residents or staff persons, or resources were needed elsewhere in the facility and such behavior was to be documented. When it was not documented, staff persons could retroactively document why in Chronos. A resident may also not get their required recreation time if they had visits or other appointments.

· Regarding a note written on IMPs about the AV not getting recreation time, P2 stated that if a staff person wrote down on the form something like “not enough time,” or “unable to accommodate,” that it probably meant staff persons had other things going on or they did not have the ability to do so, such reasons should be documented in Chronos and may not be on the form because of HIPPA rules. A resident’s programming may be cut short if they become verbally or physically aggressive.

· With respect to the AV being denied programming because s/he had refused to take medications, P2 stated that the AV was court ordered to take that medication and when the AV refused it caused a “huge safety concern.” P2 also stated that it was highly suggested that the AV take her/his medication for the safety of the AV and others. P2 referenced a court date on January 26, 2024, where this was mentioned but that the actual court order from that day did not specifically say anything about the AV taking her/his medications. P2 stated that the facility viewed the AV’s refusal to take medications as not following expectations that the court and the facility expected of the AV. P2 mentioned that there were meetings in which it was discussed denying the AV programming for refusing medications; P2 specifically mentioned a notebook with notes about the AV from meetings, but noted it might have been “shredded.”

· P2 noted that the AV sometimes would have more issues in the evening, past 4:30 p.m., but the AV would do individual recreation and leisure time. P2 went on to note that administrative separation was new at the time and it kept changing.

· Regarding cell 17, P2 stated a resident could be placed there because s/he was a threat to themselves or because they were a disruption to the rest of the unit; such as, constantly screaming in the middle of the night keeping the rest of the residents from getting a good night’s rest. P2 stated that s/he and the M raised concerns sometime after January 25, 2024, about the lights in cell 17 being on 24/7. The lighting was changed to just having a small pilot light so the resident could be seen instead of a “full blast of light in your face.” P2 could not recall when that change was made.

· When residents like the AV engage in acts of self-harm, such as scratching themselves, it would not be considered life threatening and staff persons would not “go hands on.”

· The AV was discharged from the facility on October 18, 2024, and a couple of months prior to that, on an unspecified date after July 14, 2024, the AV was moved to the non-secure unit of the facility.

Note: The facility did not provide any documentation regarding a court order or documentation of group discussions regarding withholding programming from the AV for refusing to take medications. At the time this investigator visited the facility, the lights in cell 17 were still two large panel lights.

P3 and P4 also entered comments into the AV’s IMP forms regarding the AV being denied programming because the AV refused to take her/his medications. P3 and P4 each did not respond to requests for an interview with this investigator.

The CM provided the following information:

· The CM stated that at first the AV’s behavior was fine for the most part but the assaultive behavior began with another resident and then progressed toward staff persons. After the first assault, the AV was continually on administrative separation. Attempts were made to remove the AV from administrative separation but each time the AV’s “explosive behavior,” came out. The CM stated that administrative separation could be implemented in any cell.

· A resident on administrative separation was separated from the rest of the pod in terms of programming which would depend on that resident’s IMP. Programming while on administrative separation would depend on the resident’s behavior. If the AV was doing well, s/he could program outside of the cell, such as being in the classroom as opposed to being in the day room with a staff person; eating meals with other residents as opposed to eating in the cell.

· A resident’s placement in cell 17 had to be approved by P1. Cell 17 was the only cell with cameras in it and with lights that remain on constantly, all other cells had nightlights.

· The AV engaged in acts of self-harm, picking at scabs, biting her/his arm, punching her/himself repeatedly in the face; the AV stated it was because her/his nose did not look right and s/he was trying to fix it.

· The CM stated that after the AV began receiving an injectable medication, the AV’s behavior before and after was like “night and day.” Although the AV still had moments of explosive behavior, the AV was able to calm down faster and seemed to be in control unlike before. The CM stated that “without this med, I don’t think [the AV] would have been able to program as much as [s/he] had.”

· The CM recalled an incident in cell 17 when the AV was covering her/his head and was told numerous times that staff persons needed to see that s/he was breathing and conscious. Mid to late evening, the AV was still not cooperating, and staff persons went in to remove the blanket, the AV jumped up and tried to punch a staff person. The AV had to be restrained by multiple staff persons and was placed in a WRAP.

· The CM stated that the AV was court ordered to take her/his medications and that refusing medications was also refusing court orders.

The LP provided the following information:

The LP noted that while the AV was in cell 17, s/he was allowed out of the cell to shower and to call the G. While in cell 17, the AV engaged in numerous acts of self-harm such as banging her/his head against the cell walls, biting off scabs on her/his arm, and punching her/himself in the face. The AV was not allowed to leave the cell if s/he refused medication and phone calls with the G were also denied. The LP stated that as a result of the AV’s placement in cell 17, the AV was a “shell of [her/his] former self, had no light in [her/his] eyes.”

The G stated that s/he was aware of the AV’s placement in administrative separation but believed that the facility was placed in a difficult situation when the AV was placed there by the court.

A document placed on the AV doorway to cell 5 regarding programming read as follows: “If [the AV] argues with staff, makes false allegations, threatens staff, repeatedly demands things, or harms [her/himself] or others in any way, [s/he] will not program for the rest of the day. [S/he] will remain locked down until [s/he] can be evaluated by an Administrative Staff the next business day.”

Conclusion:

A. Maltreatment:

Information showed that the VA was admitted to the facility on January 10, 2024. On January 16, 2024, the AV was placed in administrative separation after the AV had assaultive behaviors; the AV remained on administrative separation through July 15, 2024. The facility was required to document daily the need for the AV’s placement in administrative separation including why other alternatives were not available or successful and receive approval. The facility only documented the daily review of the AV’s placement on administrative separation for 10 days out of 182 days.

The cells in the general population area had windows looking out into the common area. Cell 17 in the secure perimeter area had no window or visibility outside of the cell, was away from the other resident’s area and cells, and full lights were kept on all day and night.

On January 16, 2024, when the AV was first place on administrative separation, the AV remained in the cells in the general population area. On February 11, 2024, the AV was placed in cell 17 where the AV remained until April 5, 2024, which was a total of 54 days. The AV was then placed back in a cell in the general population area but remained on administrative separation status. On April 7, 2024, the AV was placed back in cell 17 and remained there until June 6, 2024, which was a total of 60 days. From June 6 to July 14, 2024, the AV was placed in cell 5 in the general population area but remained on administrative separation status. The AV spent a total of 114 days in cell 17.

Many times, the AV was denied programming, sometimes because the AV exhibited aggressive behavior or made threats toward staff persons. Many times, throughout the AV’s placement on administrative separation, s/he refused medications, sometimes the AV still received programming such as recreation and leisure time; however, on April 8, 2024, the facility began to deny the AV programing for refusing medication and documented that on the AV’s IMP forms. Prior to April 2024, IMP records did not indicate that the AV was denied programming for refusing to take medications, although on many such occasions the AV refused to participate in programming. P2 stated that the AV was court ordered to take medications but later noted that there was no court order specifically referencing the AV taking medications. IMP records indicated that the AV was denied programming for refusing medications twelve times in the month of April 2024, and four times in May 2024. From April through July 2024, the facility did not document recreation and/or leisure time for the AV on 25 separate days. There was a note on the door of the AV’s cell in the general population area that stated, “If [the AV] argues with staff, makes false allegations, threatens staff, repeatedly demands things, or harms [her/himself] or others in any way, [s/he] will not program for the rest of the day. [S/he] will remain locked down until [s/he] can be evaluated by an Administrative Staff the next business day.”

The AV stated that while s/he was in cell 17 in the secure perimeter, the AV felt like s/he was “dying” in large part because the lights were on constantly, it messed with her/his mind and s/he went crazy because there was a lack of human interaction. The AV believed that staff persons were “tripping” her/his medications so many times the AV would refuse medications. The AV also believed that s/he heard voices of other residents wanting to hurt him/her. The AV stated that s/he had to move the mattress to the floor in cell 17 because the lights were “so bright.” The AV further stated that no kid should have to be placed in a cell like cell 17.

The M stated that being in a small area with lights constantly on, and “being by yourself more hours of the day than not,” could exacerbate the AV’s irritability, agitation, and aggressive behavior. The M stated that s/he talked to facility management about the effects of being in cell 17 had on the AV and about alternatives to cell 17 but was told that their goal was to move the AV out of cell 17 but there was no other option.

IMP records showed that the AV first engaged in acts of self-harm while on administrative separation on March 14, 2024, and numerous other acts afterwards, such as: punching walls until the AV bled, biting and scratching her/his arm until they bled, and reopening existing wounds. All but one of these acts occurred while the AV was in cell 17. P1 noted that somedays the AV would have a bandage on her/his arm. One occasion the AV was placed in the WRAP and tried to remove it. The AV was then seen by a medical professional and diagnosed with a strained shoulder. The AV was prescribed over the counter pain medication to be taken as needed.

Treatment notes provided by the M showed that the M began working with the AV on February 9, 2024, when the M provided a prescription refill for several medications. The M performed an initial evaluation of the AV on March 22, 2024, to establish care for psychotropic medication management services. Periodic changes to the AV’s medications were made by the M. On May 3, 2024, the AV received a long-acting injectable antipsychotic medication and again on May 30, 2024, which improved the AV’s mental health symptoms.

Although the AV had aggressive behaviors and the facility stated there were attempts to move the AV out of cell 17 and from administrative separation, given that the AV was in cell 17 with no windows and full lights on 24 hours a day which the AV stated increased his/her mental health symptoms for 54 consecutive days and then 60 consecutive days, that there were only 10 days that documented the review of the AV’s administrative separation out of 182 days total, that on some occasions when the AV refused mediations, s/he was refused programming, and that there was minimal documentation to show what programming the AV did receive, there was a preponderance of the evidence that the AV being in this environment for this length of time was a failure to provide care or services which were reasonable and necessary to maintain the AV’s mental health and safety and a failure to protect the AV form conditions that seriously endanger the AV’s physical and mental health.

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), 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 AV was placed on administrative separation for 182 days and was placed in cell 17 for 114 of those days. Multiple staff persons worked with the AV during this time, multiple staff persons documented refusing the AV’s programing for refusing medication, and multiple staff persons did not adequately document the AV’s programing. In addition, there were staff persons in multiple levels of authority who were aware of the AV’s administrative separation and time spent in cell 17. Therefore, the facility was responsible for maltreatment of the AV.

C. Serious Maltreatment:

The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.”

Minnesota Statutes, section 245C.02, subdivision 18, states:

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated maltreatment for which the facility was responsible did not meet statutory criteria to be determined as serious because the AV did not require the care of a physician.

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 DOC and was not required to conduct an internal review.

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

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.

The maltreatment determination 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: 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: 202200193

Date Issued: June 15, 2022

Name and Address of Facility Investigated:

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

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

License Number and Program Type:

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

Investigator(s):

Kimberly Huettl-Anderson/Rebecca Mesto
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6558

Suspected Maltreatment Reported:

It was reported that an alleged victim (AV) sustained a cut on his/her chin, which required stitches, as a result of a staff person “tackling” him/her to the floor.

Date of Incident(s): January 5, 2022

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

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on March 2, 2022; from documentation at the facility; and through seven interviews conducted with the AV, two facility staff persons (the SP and P1), an administrative staff person (P2), a social worker (SW) who worked with the AV, the AV’s case manager (CM), and the AV’s probation officer (PO). Attempts were made to contact a family member (FM) of the AV, but the FM did not respond.

The AV’s Supervision Sheet/Facility Facesheet Report stated that the AV was almost fourteen years old at the time of the incident. The AV was admitted to the facility on December 7, 2020, and had a history of second degree assault, domestic assault, and terroristic threats/threats of violence.

The AV’s Residential Program – Individual Treatment Plan stated that staff persons were trained to utilize physical and mechanical holds through the Controlled Force model. Restrictive procedures staff persons could utilize with the AV included physical escort and physical holding, individual reflection time, and mechanical restraints as needed. Time outs were to be used as a behavioral management tool when children were “acting out” or causing a disturbance.

The facility was a children’s residential facility that provided treatment, training, and detention for juveniles and was licensed by the Minnesota Department of Corrections. The facility had a timeout room, where individuals were taken if they were not following directions or if they were becoming aggressive. The timeout room was a small, empty room and had a video camera that recorded time spent in that room.

Video footage of the incident in the timeout room showed the SP holding the AV against a corner, with the AV’s hands secured behind his/her back by the SP. P1 was standing near an adjacent wall, watching the SP and the AV. The SP quickly moved the AV to the right, swinging him/her to the floor, while securing the AV’s hands behind his/her back. One of the AV’s sandals fell off. It was unclear if the AV hit his/her face or chin on the floor, but was on his/her stomach and the SP was using his/her body weight to attempt to keep the AV on the floor. The AV was moving his/her legs around and P1 then held the AV’s feet and at the same time, P3 entered the room. The AV continued to move around on the floor and the SP readjusted his/her position. The AV moved toward the wall and was on his/her side and then the AV’s upper body came off of the floor and P3 and the SP put the AV’s upper body back onto the floor, and the AV’s face/chin may have hit the floor. The SP and P3 each took a side of the AV’s body and held the AV on the floor, in a prone position with his/her hands behind his/her back. After about four minutes, the SP left the room and ten seconds later, the AV sat up in a seated position and P1 and P3 appeared to talk with the AV. Blood could be seen on the floor and then P3 administered first aid to the AV. The AV had a slim build and the SP was considerably taller and had a large build.

The AV provided the following information:

· The AV said it had been going “up and down” at the facility.

· At the time of the incident, the AV was having a “really rough” night and was “really angry.” The AV got mad and repeatedly hit the wall unit in his/her bedroom. The SP told the AV to stop and the AV told him/her s/he was not going to stop and continued hitting the wall unit. The SP asked the AV to sit out in the hallway and so s/he sat out in front of his/her door. The AV swore at the SP and said s/he was not going to sit there and that s/he should go to the timeout room. The AV said s/he was in a mood where s/he was either going to hurt him/herself or someone else. The AV asked the SP to let him/her walk on his/her own to the timeout room, but the SP asked the AV to sit out by the unit door, which the AV did for five seconds. Then the AV got “really mad” and swore at the SP and the SP told him/her that s/he was going to timeout. The AV said s/he was going to hurt him/herself or someone else. The SP told the AV to sit down and calm down, because s/he did not want the AV to go to timeout. The AV told the SP, “No,” and turned the handle of the unit room door, which was a “big thing” because it was a “run risk.” The SP and another staff person (P4) then restrained the AV by holding his/her arms behind his/her back. The SP put the AV in a “butterfly” hold, told the AV to calm down, and led the AV toward the timeout room. The AV turned his/her body sideways and pushed the SP into the wall and “kept fighting” the SP. Two other staff persons came and opened the timeout room door. The SP put the AV into the corner and asked the AV to kneel. The AV refused to kneel and started elbowing the SP. Then the SP picked up the AV by his/her arms and the AV’s face “accidentally” hit the wall and then the AV’s chin hit the floor because the AV did not have his/her hands in front of his/her body. The SP immediately fell after the AV did, was still holding the AV, and then picked the AV up and, “accidentally” set the AV down on the floor and the AV hit his/her chin again. That is when the AV noticed his/her chin “busted open.” The AV went to the emergency room and received six or seven stitches.

· The AV said that the injury was caused partly because s/he was fighting “pretty hard,” trying to get out of the restraint and the SP was trying to let the AV down “easier” than s/he did. During the incident, the SP tried to put the AV down “nicely” and tried to put his/her hand down to break the AV’s fall. The SP did not intentionally try to injure the AV.

· The SP was “very helpful,” was a good listener, and was a “great staff” and everyone missed him/her at the facility.

The AV’s Contact Detail and the facility’s Documentation of Time-Out provided the following information:

· The AV was taking medication and having therapy to address attention deficit hyperactivity disorder, major depressive disorder, and oppositional deviant disorder. Staff persons were not to interact with the AV if s/he was defiant, aggressive, and/or verbally abusive. The timeout process was to be utilized to give the AV an opportunity to deescalate.

· At 7:31 p.m. on January 5, 2022, the AV had a “time out” after s/he did not follow directions from a staff person. The AV was asked to “sit out” (sit on the floor in the hallway). While the AV was sitting out, s/he told the SP that s/he was going to “piss on [the SP’s] grave.” After P4 asked the AV to stop talking, the AV got up and “went after” P4 so the SP secured the AV by his/her upper bicep and escorted the AV to the timeout room. At 7:33 p.m., the AV refused to follow directions, was verbally combative, and would not allow staff persons to exit safely, and therefore a physical hold was initiated. At 7:35 p.m., the AV was released from the hold, blood was seen on the AV’s face, and five minutes later, a staff person cleaned the AV’s chin and provided first aid. The AV was then taken to the emergency room.

· It was noted that P1 witnessed the SP put the AV in a “bear hug” and escorted him/her to the timeout room and P1 followed. The AV told the SP that s/he was going to “kill” him/her multiple times. The SP and P1 asked the AV to kneel so that they could safely leave the room, but the AV did not comply. The SP “lowered” the AV to the floor and the AV’s chin hit the floor. The AV was kicking so P1 secured his/her legs and then P3 entered and assisted the SP and P1 to secure the AV in a “transitional handcuffing” position. The AV continued to verbally threaten staff persons and was “combative” while on the floor. Then they saw that the AV was bleeding from the right side of his/her chin and P3 asked the SP to leave the room. P1 took over the right side of the AV’s body and the SP left the room. When the AV sat up, staff persons supplied the AV with first aid and then s/he was transported to the emergency room where s/he received stitches.

P1 provided the following information:

· On the day of the incident, P1 saw the SP lead the AV to the timeout room, so P1 followed them. In the timeout room, the SP had the AV standing in the corner and P1 thought the SP was going to keep the AV there, as they typically would, but then the AV tensed up and the SP put the AV on the floor. Typically an individual was only taken to the floor if s/he was combative or was a danger to someone else. P1 believe that the way the SP put the AV to the floor was “excessive.” Then, P3 came in and helped the SP to secure his/her upper body and P1 secured the AV’s legs. P1 and P3 asked the SP to leave the room because the AV was mad at the SP and after the SP left, the AV was “fine,” and relaxed. When the AV sat up, P1 noticed blood on his/her face and first aid was administered.

· Prior to the incident, P1 did not have any concerns with the way the SP interacted with the individuals..

P2 provided the following information:

· The AV was “very defiant” and challenged staff persons.

· The SP typically followed rules “to a T” and P2 did not have any prior concerns with the way the SP interacted with the individuals. P2 watched the video of the incident and said that the SP’s actions were not consistent with his/her training and that the SP “flung” the AV to the floor. The AV received medical attention and had three stitches on his/her chin.

· After the incident, the SP called P2 and said that the AV would not sit down and the SP said s/he was worried that s/he may have hurt the AV.

The CM provided the following information:

· Prior to the incident, the CM had concerns regarding the SP’s interactions with children and other staff persons at the facility. The SP was not respectful of some of the other staff persons, s/he had “control issues,” and used sarcasm when working with the children, which was “inappropriate.”

· After the incident, the AV told the CM that s/he was being a “punk kid,” and deserved what happened.

The SP provided the following information:

· On the day of the incident, the AV had been yelling, arguing with staff persons, punching the door, and calling staff persons names. The AV was directed to sit out by his/her bedroom door but did not comply. The SP directed the AV to move out of the sight of another individual and then s/he began arguing with P4. The SP saw the AV move toward the other staff person, like s/he was “going after” him/her, so the SP secured the AV’s arms behind his/her back and led him/her to the timeout room. While walking to the timeout room, the AV was being “combative,” flexing his/her arms, and yelling. In the room, the SP asked the AV to kneel down so that s/he could safely exit the room, which the SP had done “many times” with the AV, but during this incident, the AV pushed out of the hold and threatened to kill the SP. The AV refused to kneel and told the SP that if s/he let go, s/he would kill the SP. The SP told the AV to calm down and kneel again, and the AV began to push back out of the corner “a little.” The SP then decided to “lower” the AV down to the floor to prevent the AV from punching him/her when the SP let go of his/her arms. The SP “twisted” “too quickly,” underestimated his/her “own strength,” and when they went down, the AV’s chin hit the floor, causing it to split open. Then P3 came in and assisted the SP in getting the AV into a transitional handcuff position. The SP then saw that the AV was bleeding and because the AV was not calming down, the SP left the room. The AV was taken to the emergency room and received stitches. When the AV came back, the AV told the SP that the AV “deserved it.” The SP told the AV that s/he deserved to go to timeout, but did not deserve a split chin.

· After reviewing the video footage and talking with supervisors and coworkers regarding the incident, the SP stated that s/he should have directed the AV to timeout right away and “could have” released the AV because the AV had never punched the SP previously, or the SP could have asked P1 to get another staff person or ask P1 to hold the other side of the AV. The SP stated that the restraint and takedown of the AV was not done in accordance to his/her training, but the SP had done the same thing “multiple” times prior.

· The SP stated that in the past, s/he had placed many children in holds and had lowered them to the floor in the same manner, without injury. During this incident, the SP lowered the AV to the floor to get “better control” of the situation. The SP did not lower the AV to the floor “out of anger,” and after the incident, the SP was “emotional” and felt “terrible” that s/he “hurt” the AV. The SP had a good rapport with the children, including the AV.

· The AV had a history of being aggressive with other children and staff persons. In the months prior to the incident, the AV had been more argumentative and combative.

The SP’s Staff Discipline Document, dated September 1, 2020, stated that the SP received a written reprimand after another child sustained rug burns and a swollen lip after the SP took him/her to the floor. The SP was retrained on controlled force measures.

The SP’s Staff Discipline Document, dated January 7, 2022, stated that on January 5, 2022, (this incident) the SP used “excessive force” to take the AV to the floor, using a technique that was not approved by the facility.

The PO stated that the AV was a “difficult kid.” The PO did not have any concerns regarding the overall care the facility provided to the AV.

The SW did not have any concerns about the care provided to the AV by the facility.

The facility’s Use of Restrictive Procedures Policy Plan stated that prior to using physical holding techniques, staff persons must exhaust less restrictive/intrusive methods to deescalate crisis situations.

Facility documentation showed that the SP received training on proper use of mechanical holds and the Reporting of Maltreatment of Minors Act prior to the incident.

Conclusion:

A. Maltreatment:

On January 5, 2022, the AV sustained a cut on his/her chin and received stitches after being taken down to the floor by the SP.

Video footage showed that the SP quickly moved the AV from a standing position in the corner of the timeout room, to a prone position on the floor. The AV may have hit his/her face/chin on the floor. Then P1 restrained the AV’s feet and P3 came in and restrained one side of the AV’s body while the SP restrained the other side. The AV’s body lifted up and then the AV’s body and face went back onto the floor. Blood could be seen on the floor, under the AV’s face.

The AV stated that the SP did not intentionally try to injure the AV and that during the altercation, the AV “kept fighting” the SP. The SP and the AV both fell to the floor and the SP attempted to stop the impact by putting his/he hand down.

The SP stated that the AV was being “combative” while s/he restrained the AV’s arms behind his/her back. When the SP had the AV in the corner of the timeout room, the AV pushed back out of the corner and the SP decided to lower the AV to the floor, but “twisted” “too quickly” and when they went to the floor, the AV’s chin hit the floor. Then, when P3 came into the room and s/he and the SP had the AV in a handcuff position on the floor, they noticed the AV was bleeding.

However, P1 was in the timeout room at the time of the incident and stated that the way the SP took the AV to the floor was “excessive” and that s/he noticed blood on the AV’s face after the incident; P2 watched the video and said that the SP’s actions were not consistent with his/her training; and the SP’s Staff Discipline Document stated that the SP used “excessive force” when taking the AV to the floor, using a technique that was not approved by the facility.

Although the AV may have required physical intervention, the manner in which the SP put the AV onto the floor was not accidental or therapeutic, not consistent with his/her training, and caused injury to the AV. Therefore, there was a preponderance of the evidence that there was injury to the AV inflicted by a staff person by means other than accidental and that there was a failure to supply the AV with necessary care and a failure protect the AV from conditions or actions that endangered the AV’s physical or mental health when reasonably able to do so.

It was determined that 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).

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), 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 Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incident. The SP was responsible for the care of the AV at the time of 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 and neglect for which the SP was responsible was not recurring maltreatment because it was a single incident that met two definitions, but was serious maltreatment because the AV sustained a laceration and required medical treatment in the form of stitches to his/her chin.

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 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.

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


facility_name: Northwood Children's Services-Main Campus

report_date: January 24, 2025

raw_content:
January 24, 2025

Melissa Winkler, Authorized Agent

Northwood Children’s Home Society, Inc.

714 W College Street

Duluth, MN 55811

License Numbers:

801775 Northwood Children’s Services-Main Campus (CRF)

1091513 Northwood Children’s Services Inc.-Diagnostic Assessment Center (CRF)

CORRECTION ORDER

Dear Melissa:

On December 2 through 5, 2024, Department of Human Services (DHS) licensors conducted licensing reviews at your facilities, Northwood Children’s Services-Main Campus located at 714 W College Street, Duluth, MN 55811 and Northwood Children’s Services, located at and 4000 W 9th Street, Duluth, MN 55807. These reviews were conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, shelter care services under Minnesota Rules, part 2960.0510 through 2960.0530, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, restrictive techniques standards under Minnesota Rules, part 2960.0710, residential program certification for compliance with the Family First Prevention Services Act, Minnesota Statutes, section 245A.25, and crisis stabilization services under Minnesota Statutes, section 245A.26. 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.

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

· Northwood Children’s Services-Main Campus: (Main);

· Northwood Children’s Services: (DAC); and

· When citations are specified to all licensed programs: (ALL).

LICENSING VIOLATIONS

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

Physical Plant

1. Violation: A copy of the resident’s basic rights was not posted in the staff work station (All).

Rule Violated: Minnesota Rules, part 2960.0050, subpart 3, item D.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 resident rights are posted in the staff work station and meet all applicable requirements. This violation was corrected during the licensing review, no further corrective action is required.

Policies, Procedures, and Practices

2. Violation: The license holder’s annual review of the plan for the transfer of clients and records upon closure did not meet requirements (All). A controlling individual did not annually review and sign the plan for calendar years 2022 and 2023.

Statute Violated: Minnesota Statutes, section 245A.04, subdivision 15a, paragraph (a).

Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the plan for transfer of clients and records upon closure meets all applicable requirements.

3. Violation: Two of two internal reviews of alleged maltreatment of minors did not meet requirements (Main). The internal review did not include an evaluation of whether related policies and procedures were followed for reviews dated September 20, 2024, and November 5, 2024.

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

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that internal reviews of alleged maltreatment meet all applicable requirements.

4. Violation: The license holder did not have documentation that they conducted an annual evaluation of the program’s strengths and weaknesses according to performance indicators identified in Minnesota Rules, part 2960.0060, subpart 3, item A, for calendar years of 2022 and 2023 (All).

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

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that the annual evaluation of the program’s strengths and weaknesses meets all requirements. Within 60 days receipt of this order, submit the annual evaluation for the calendar year 2024 for both Main and DAC programs.

5. Violation: The license holder’s review of the use of restrictive procedures did not meet requirements (All). The license holder did not have documentation of the following:

a. Quarterly reviews of the use of restrictive procedures for 2022, Quarter 4; 2023, Quarters 1 through 4; and 2024, Quarters 1 through 3.

b. An annual written evaluation of the use of restrictive procedures for the years of 2022 and 2023.

Rule Violated: Minnesota Rules, part 2960.0710, subparts 2, item D, and 11.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that the reviews of the uses of restrictive procedures meet all requirements. Within 30 days receipt of this order, submit the 2024 Quarter 4 review for both Main and DAC programs.

6. Violation: The license holder’s staffing ratios did not meet requirements (Main). On June 17, 18, 19, and 23, 2024, documentation identified times that the Cubs unit had two staff on the schedule during normal waking hours with nine residents on the unit, the youngest being six years old.

Rule Violated: Minnesota Rules, part 2960.0690, subpart 2, item B.

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

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

a. For the week of June 16 through 22, 2024:

i. One of thirteen staff did not attend (Evergreen); and

ii. One of twelve staff did not attend (Eagles).

b. For the week of November 24 through 30, 2024:

i. There was no documentation that clinical supervision occurred (Cub);

ii. Three of thirteen staff did not attend (Eagles); and

iii. Three of nine staff did not attend (Evergreen).

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

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 clinical supervision meets all applicable requirements.

Personnel

8. Violation: One of five personnel files reviewed for staff qualifications did not meet requirements (All). The license holder did not have documentation showing that the staff’s professional licensure was current (personnel file numbered 2).

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

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

9. Violation: One of seven personnel files reviewed for orientation did not meet requirements (All). The license holder did not orient the staff person to the required topics (personnel file numbered 1).

Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivisions 1, paragraph (c), and 14, paragraph (b), 245A.25, subdivision 3, paragraph (e), and Minnesota Rules, parts 2960.0100, subparts 3, item A, and 5, 2960.0150, subpart 4, item C, and 2960.0650, subpart 1, items A, B, D, E, F, and G.

Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute and rule.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that orientation training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that personnel numbered 1 was oriented to emergency procedures, maltreatment of minors reporting requirements under Minnesota Statutes, section 260E, and operational policies and procedures of the license holder, including grievance procedures.

10. Violation: Three of eleven personnel files reviewed for ongoing training did not meet requirements in the following ways (All):

a. The staff person did not receive annual training on the maltreatment of minors reporting requirements and definitions in chapter 260E (personnel file numbered 1);

b. The emergency plan was not reviewed with staff at least once every six months (personnel files numbered 1, 6, and 8); and

Statute and Rule Violated: Minnesota Statutes, section 245A.66, subdivision 4, and Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subparts 3, item B, and 5.

Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute and rule.

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

Residents

11. Violation: Five of six resident files reviewed for resident information did not meet requirements (All). Documentation in the resident’s file did not contain:

a. The placing agency’s case plan goals for the resident (resident file numbered 3); and

b. Contact information for all known biological family members and fictive kin of the resident (resident files numbered resident information 1, 2, 4, and 5).

Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph (g) and Minnesota Rules, part 2960.0070, subpart 3, item B.

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

12. Violation: Five of six resident files reviewed for admission procedures did not meet requirements (All).

a. The inventory of the resident’s personal property was not signed by the resident or two staff members if the resident refused to sign (resident files numbered 2 and 4);

b. There was not documentation to demonstrate that the license holder informed the resident how to contact the appropriate state appointment ombudsman or that they gave the resident the name, address, and phone number of the state-appointed ombudsman (resident files numbered 2, and 4 through 6); and

c. There was not documentation that within 12 hours of admission the resident’s immediate needs were assessed that included the need for connection to family and other natural supports (resident file numbered 3); and

d. Admission procedures were not completed for the resident’s August 14, 2024, intake at the Main campus. The resident file contained admission documentation that was completed for a previous intake at the DAC campus (resident file numbered 2).

Statute and Rule Violated: Minnesota Statutes, section 245A.26, subdivision 5, paragraph (a), and Minnesota Rules, parts 2960.0050, subpart 3, items A, B, and E, 2960.0070, subpart 4, 2960.0080, subpart 4, and 2960.0160, subpart 4, items A, B, and C.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that admission procedures meet all applicable requirements.

13. Violation: Five of six resident files reviewed for program services did not meet requirements (All). The license holder did not have documentation to demonstrate:

a. That they contacted and facilitated outreach to the resident’s siblings (resident files numbered 1 and 2); and

b. That they were offered crisis stabilization services as described in Minnesota Statutes, section 256B.0624, subdivision 7 (resident file numbered 3).

Statute Violated: Minnesota Statutes, sections 245A.25, subdivision 4, paragraph (g) and 245A.26, subdivision 4, paragraph (b).

Repeat Violation: In a Correction Order that DHS issued on September 10, 2021, you were previously found in violation of this same statute.

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

14. Violation: Three of five resident files reviewed for treatment plans did not meet requirements in the following ways (All):

a. Treatment plans did not include:

i. The use of restrictive procedures (resident file numbered 4);

ii. How the program maintains the youth’s connections to their siblings (resident files numbered 1 and 2);

b. The crisis treatment plan did not include (resident file numbered 3):

i. Crisis assistance strategies that have been effective in the past;

ii. Measurable treatment objectives;

iii. Specific interventions the license holder will use to help the resident engage in treatment; and

iv. Documentation of referrals to and scheduling of services, including specific providers where applicable.

Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 4, paragraph (h) and 245A.26, subdivision 5, paragraph (b), and Minnesota Rules, part 2960.0710, subpart 6, item F.

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

15. Violation: Four of six resident files reviewed for service plan reviews did not meet requirements in the following ways (All):

a. The treatment team did not include and document the review of the use of time-out for the resident during the review of the resident’s treatment plan (resident files numbered 1, 2, and 5); and

b. There was not documentation to demonstrate that the resident’s crisis treatment plan was reviewed each week by a mental health professional (resident file numbered 3).

Statute and Rule Violated: Minnesota Statutes, section 245A.26, subdivision 5, paragraph (c) and Minnesota Rules, part 2960.0080, subpart 5, item D.

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

16. Violation: Six of six resident files reviewed for health care did not meet requirements in the following ways (All):

a. There was not documentation to support that the license holder contacted the newly admitted resident’s prescribing medically licensed person to verify the following information:

i. Instructions about how the medication must be administered (resident files numbered 2 through 5);

ii. The symptoms that the medication will alleviate (resident files numbered 1 through 5); and

iii. The symptoms that would warrant consultation with the physician (resident files numbered 1 through 5).

b. The license holder did not have documentation of the disposition of the resident’s medication or that prescription medication belonging to the resident was given to the resident’s parent or legal guardian upon the resident’s discharge (resident file numbered 6).

Rule Violated: 2960.0080, subpart 11, items D and F.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that health care meets all applicable requirements. Within 30 days receipt of this order, submit verification documentation of a newly admitted resident verifying the information in item a.

17. Violation: One of four resident files reviewed for psychotropic medication reviews did not meet requirements (Main). Psychotropic medication reviews completed on August 29, September 26, and November 21, 2024, did not include side effects observed and actions taken (resident file numbered 2).

Rule Violated: Minnesota Rules, part 2960.0620, subpart 5, item C.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that psychotropic medication reviews meet all applicable requirements.

18. Violation: Four of four resident files reviewed for informed consents did not meet requirements (Main). The information communicated in obtaining consent for psychotropic medications did not include:

a. The level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed (resident files numbered 2 and 4);

b. The expected benefits of the medication, including the level to which the medication is to change the symptoms and behavior and an indication of the method used to determine the expected benefits (resident file numbered 1);

c. Specific information about the psychotropic medication to be used, including the rote of administration (resident file numbered 1);

d. The pharmacological and nonpharmacological treatment options available and the course of the condition with and without the treatment options (resident files numbered 1, 3, 4 and 5); and

e. The more frequent and less frequent or rare but serious side effects of the psychotropic medication, including how the risks and possible side effects must be managed (resident file numbered 5).

Rule Violated: Minnesota Rules, part 2960.0620, subpart 7, items A, B, C, D, and E.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that informed consents meet all applicable requirements. Within 30 days receipt of this order, submit informed consent documentation for one resident to demonstrate compliance.

19. Violation: One of five resident files reviewed for time out procedures did not meet requirements (Main). In a time out utilized on September 8, 2024, documentation did not include the resident’s response to the time out or the resident’s ability to de-escalate during the time out (resident file numbered 2).

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 that time out procedures meet all applicable requirements.

20. Violation: One of five resident files reviewed for restrictive procedures did not meet requirements (Main). In a physical hold that occurred on July 24, 2024, documentation did not demonstrate that the physical hold was necessary to protect the resident or others from physical harm, that it was the least intrusive intervention that would effectively react to the emergency, or a detailed description of the incident which led to the use of physical holding (resident file numbered 1).

Rule Violated: Minnesota Rules, part 2960.0710, subpart 6, items A, B, and K.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that restrictive procedures meet all applicable requirements. Within 30 days receipt of this order, submit documentation that staff persons involved in the restrictive procedure used on July 24, 2024, have been retrained in restrictive procedures policies.

21. Violation: One of four resident files reviewed for discharge procedures did not meet requirements (Main). There was not documentation that the license holder returned all of the resident’s personal property to the resident along with a signed receipt upon discharge (resident file numbered 4).

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

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that discharge procedures meet all applicable requirements.

22. Violation: Three of three resident files reviewed for transition services plans did not meet requirements (All). The license holder did not have documentation to demonstrate:

a. That the plan was developed with input from the resident, the resident’s family, the providing school district, and the persons who will provide support services to the resident upon release (resident files numbered 4 and 5); and

b. That the plan included a budget plan and a description of the resident’s financial and employment status or transportation needs (resident file numbered 6).

Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, items A and B.

Repeat Violation: In a Correction Order that DHS issued on September 10, 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 that transition services plans meet all applicable requirements.

Written Response Required

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

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

Commissioner, Department of Human Services

ATTN: Hannah Horsch

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

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

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

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

Questions

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

Sincerely,

Hannah Horsch, Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


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: Northwood Children's Services-West Campus

raw_content:
May 15, 2026

Melissa Winkler, Authorized Agent

Northwood Children’s Home Society

714 W. College Street

Duluth, MN 55811

License Number: 801777 (PRTF)

Dear Melissa Winkler:

The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration regarding citation 3, paragraph b, and citation 8 in the Correction Order issued to you on February 4, 2026. After an independent review of the record, the Commissioner has determined it is appropriate to rescind paragraph b of citation 3. Citation 8 is affirmed. Also, the violations for which you did not request reconsideration are final and not within the scope of this review.

Reconsideration Determination

Violation 3: The license holder did not ensure the residents’ rights were protected in the following ways:

a. The license holder did not comply with rights under Minnesota Statutes, section 144.651, subdivision 23, services for the facility. Residents were responsible for performing labor for the facility by having residents clean on the units without the labor being therapeutic or appropriately goal related; and

b. Residents were not allowed to participate in the development of their treatment plan.

Applicable Law

Under Minnesota Variance, section R2960V.04, subpart 1, a resident has basic rights including, but not limited to, the rights in this subpart. The license holder must ensure that resident rights are protected. Resident rights include the right to participate in development of the resident’s treatment and case plan.

Your Response

You submitted a letter in which you indicated the citation was incorrect, and you submitted supporting documentation. You challenged only paragraph b of the violation.

Reconsideration Determination

After further review of the information contained in the file and the information you submitted, the Commissioner has determined it is appropriate to rescind paragraph b of the violation.

Violation 8: The license holder did not meet requirements governing healthcare services. Schedule II drugs were not stored in a separately locked compartment from other medications.

Applicable Law

Under Minnesota Variance, section R2960V.08, subpart 5, item 1, a license holder must have in place and implement written policies and procedures developed by a registered nurse that contains the following provisions: 1) A requirement that all drugs must be stored in a locked compartment. Schedule II drugs, as defined by Minnesota Statutes, section 152.02, must be stored in a separately locked compartment, permanently affixed to the physical plant or medication cart; 2) A system which accounts for all scheduled drugs each shift; 3) A procedure for recording the client’s use of medication, including the signature of the administrator of the medication with the time and date; 4) A procedure for destruction of discontinued, outdated, or deteriorated medications; 5) A statement that only authorized personnel are permitted to have access to the keys to the locked drug compartments; and 6) A statement that no legend drug supply for one client will be given to another client.

Your Response

You submitted a letter in which you indicated the violation was incorrect because Schedule II medications were behind two locks and in a separate compartment in both the nurses’ office and staff offices. You also indicated the medications were always kept separated and were in the nursing office from approximately 7:00 p.m. until 7:00 a.m. You submitted photographs showing where medications were stored.

Reconsideration Determination

During the licensing visit, the program indicated that Schedule II drugs were stored overnight in a locked cabinet in a central nursing office and that during the daytime, a nurse would bring all Schedule II drugs to each unit to be stored in the unit’s staff office with the rest of the medications. Licensors observed during the visit that when the Schedule II medications were on each unit in the staff office, the medications were kept in a separate cubby of the locked medication cabinet labeled “narcotics.” However, the cubby does not have an additional separate lock. The variance requires Schedule II drugs to be stored in a separately locked compartment, permanently affixed to the physical plant or medication cart. There is sufficient information to support the violation, and it is therefore affirmed.

Disposition

The Commissioner has reviewed the relevant laws and all the information you submitted in response to the Correction Order. Paragraph b of violation 3 is rescinded. The remaining violation for which you requested reconsideration is affirmed, and the violations for which you did not request reconsideration are affirmed. DHS will issue an Amended Correction Order. 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/