report_date: October 18, 2024

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: 202407522

Date Issued: October 18, 2024

Name and Address of Facility Investigated:

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

Disposition:

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

Allegation Two: Maltreatment not determined.

License Number and Program Type:

831080-CRF (Children’s Residential Facility)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
beth.virden@state.mn.us

651-431-6572

Suspected Maltreatment Reported:

Allegation One: It was reported that an alleged victim (AV) accessed a staff person’s (SP1’s) personal bag and “overdosed” on SP1’s prescription medication found in the bag. The AV was “mumbling, slurring [his/her] speech.” Staff brought the AV to an emergency room where s/he received intravenous fluids and was released back to the facility that same day, unharmed.

Allegation Two: The AV “threatened to vomit” on a staff person (SP2) and in response, SP2 “swung” at the AV.

Date of Incident(s): August 28, 2024

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

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 18, 2024; from documentation at the facility and medical records; and through interviews conducted with the AV, the AV’s family member (FM), facility staff persons (SP1, SP2, and P1), and supervisory staff persons (P2 and P3).

According to the facility’s website, www.nexusfamilyhealing.org, the facility provided short- and long-term residential treatment programs for youth, ages 16-21, in need of intensive support and care.

In January 2024, the AV, who was 17 years old, moved into the facility. The facility provided the AV with individual and family therapy, psychiatry, medication management, and education.

The AV did not remember details of what happened during the incidents. [Note: This was believed due to the AV’s level of intoxication at the time.] The AV told this investigator that s/he liked some aspects of living at the facility and some of the staff, but not all. The AV did not believe s/he always received adequate services, including counseling sessions or skills specific to his/her needs. According to the AV, most of the programming was geared towards mental health and the AV believed s/he needed services geared towards behavioral needs.

Facility documentation stated that SP1, SP2, P1, P2, and P3 received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act.

Allegation One: It was reported that the AV accessed SP1’s personal bag and “overdosed” on SP1’s prescription medication found in the bag. The AV was “mumbling, slurring [his/her] speech.” Staff brought the AV to an emergency room where s/he received intravenous fluids and was released back to the facility that same day, unharmed.

The AV’s support plans stated that s/he had a history of substance abuse, suicidal ideation with at least one attempt, and self-harm and physical aggression in response to high-stress situations.

The facility had more than one dormitory (dorm) for the youth. The AV’s dorm had a dayroom and a long hallway off one side for the youths’ bedrooms, bathrooms, etc. The dayroom was divided into two sections by a shelving unit. One side was a lounge with various couches and chairs (herein referred to as the lounge) and the other side had round tables with chairs (the dorm dining room).

There was also a larger dining room for all the dorms’ youths’ communal meals (the central dining room). The central dining room was in a different part of the building than the AV’s dorm.

P1-P3 and the AV’s medical records provided the following information:

· On August 28, 2024, around noon, SP1 brought the youth to the central dining room for lunch.

· P3 said that most youth ate meals in the central dining room; however, the AV struggled being around all of the youth at one time. The AV and staff agreed that it was best for the AV to eat his/her meals in the dorm dining room.

· On August 28, 2024, after the youth left for lunch, P2 stayed in the dorm with the AV. The AV’s lunch was delivered, which the AV grabbed and moved into the lounge to eat. The AV sat on a couch facing away from P2. P2 could see the back of the AV’s head but could not see the AV’s body below his/her shoulder line.

· When lunch was finished the AV went to school, which was in a separate area of the facility.

· P1 worked in the school. When the AV arrived, P1 noticed the AV “seemed out of it. Not [his/her] normal self. Something was off.” The AV struggled to pronounce words and had a “glossy look” in his/her eyes. P1 contacted staff and escorted the AV back to his/her dorm.

· Once back at the dorm, the AV told P2 that s/he was not feeling well and went to his/her bedroom. At one point, the AV went into the bathroom and took a shower before returning to his/her bedroom. P2 checked on the AV and observed the AV “slurring” his/her words and forgetting things. P2 then noticed the AV had vomited and defecated in the shower. P2 called staff and prepared to take the AV to an emergency room. During this time, or around 3 p.m., SP1 approached P2 and said that s/he had mistakenly left his/her bag unattended in the dorm dining room during lunch time. After lunch, SP1 found the bag and put it away in the staff locked closet. At that time, SP1 did not look inside the bag or check to ensure his/her belongings were still present. However, when SP1 was preparing to leave for the day at 3 p.m., s/he noticed that his/her prescription pill bottles were not in his/her bag as they had been earlier that day.

· The AV’s medical records stated that at 4:48 p.m., the AV arrived at the emergency room with staff. Healthcare professionals (HCPs) were able to determine based on the AV’s statements and what was missing from SP1’s bag that the AV “overdosed” on 26 Ativan (anti-anxiety) 0.5 milligram (mg) pills and 30 buspirone (anti-anxiety) 10 mg pills. The AV told the HCPs that s/he took the pills to “get high.” The AV’s blood laboratories and vital signs were checked and within normal limits. The AV appeared oriented and without distress. The AV was given two liters of intravenous fluid and monitored in the emergency room. The AV did not develop worsening symptoms or signs of drug toxicity, and was released back to the facility at 7:53 p.m.

· P3 said that some of the buspirone pills were later found in the AV’s bedroom. By the time the AV returned from the emergency room, all of the Ativan and buspirone pills were accounted for or found.

· P2 did not have prior concerns with SP1’s conduct. “At all points in time” prior to August 28, 2024, SP1 kept his/her bag locked in the staff closet.

· P3 said that some staff carried satchels with them to hold their radios and other work-related items. Personal items, including bags and medications, were supposed to be locked in the staff closet. SP1 did not have a history of leaving personal items unattended or any previous, related incidents.

· P2 and P3 each said that there was not training specific for each youth. Staff attended weekly meetings, in which pertinent information about each youth was discussed, and when a youth moved into the facility, the counselors shared information about that youth’s history, including substance abuse or other concerns. SP1 attended these meetings, in which, at various points the AV would have been discussed. Although the AV had a history of substance abuse, the facility did not provide substance abuse treatment, and this was not something that would have been focused on with the AV’s care or services.

The facility’s camera footage was provided for the investigation and showed the following for August 28, 2024:

· Between 11:15:00 a.m. and 12:15:17 p.m., SP1 sat at a table in the dorm dining room across from another staff person with laptop computers and various paperwork. SP1 stood up at various points and completed unidentified tasks. SP1 was not carrying a bag during this time and there was not a bag obviously visible on the table or hung on the back of SP1’s chair at the table. [Note: The camera system was such that it recorded when there was movement. There were many cameras, which were individually activated as movement occurred through the space. When the movement stopped or moved out of the space, the camera deactivated.]

· At 11:49:30 a.m., the AV entered the dorm.

· At 12:08:08 p.m., the AV walked into the lounge, which activated the camera in the lounge to start recording. The AV sat down on a couch, which was facing away from the dorm dining room where the staff were situated. There was a brown item on the couch cushions. The AV grabbed the item and looked at it, while also glancing up over the back of the couch and shelving unit, talking to SP1. From where SP1 was standing, s/he could not see the AV’s body below his/her shoulder line. The lounge camera then shut off due to a lack of movement.

· At 12:08:54 p.m., the lounge camera reactivated and showed the AV standing up from the couch and adjusting or touching his/her waistline or pockets. The AV walked out of the dayroom and down the hallway towards the youth bedrooms and bathrooms. The AV put his/her hand in his/her right pocket and walked into a bathroom. There was not a camera in the bathroom. At 12:10:50 p.m., the AV exited the bathroom and approached SP1 who was interacting with another youth (Y). The AV kept his/her hand in his/her right or left pocket during this time.

· At 12:15:18 p.m., SP1 went to the main entrance of the dorm and left through the door. SP1 was not carrying a bag. The AV leaned against a wall watching SP1’s movements. The AV had his/her hand in his/her left pocket. The AV removed his/her hand and appeared to have something very small between his/her fingers. SP1 walked past and out of the dorm. The AV then brought his/her right hand up to his/her mouth. P2 was nearby sitting in a chair facing the bedroom hallway.

· At 12:20:47 p.m., an unidentified staff person arrived carrying two lunch trays. The AV and the Y each took one. The Y sat at a dining table and the AV sat on the same lounge couch as earlier.

· At 12:33:39 p.m., the AV walked down the bedroom hallway activating various cameras at s/he went. P2 was sitting in a chair facing the hallway; however, would have only been able to see the AV’s back during this time. At one point, the AV pulled an item out of his/her left pocket. At another point, a camera was activated that showed the AV from the front. The AV was holding and looking at a pill bottle in his/her hands. The AV entered his/her bedroom at 12:34:47 p.m.

· At 12:37:24 p.m., the AV exited his/her bedroom and walked back to the dining room and stood in front of a Dutch door at the far end of the room. The AV appeared to be walking normally during this time.

· At 12:42:00 p.m., the AV was squatting in front of the Dutch door and fell over but corrected him/her and continued squatting with his/her hands to his/her face. The AV then stood and walked back down the hallway, past P2, and appeared to be walking without issue. The AV entered his/her bedroom.

· At 12:55:54 p.m., the AV walked back towards P2 and the dorm dining room. The AV appeared to be walking normally during this time. The AV walked into the dining room, sat down, and put his/her head down on the table. SP1 had returned to the dorm at this point.

· At 1:02:15 p.m., SP1 opened the main entrance and appeared to prompt the AV to go to school. The AV stood and walked to the door without apparent issue. However, SP1 stepped away making the AV wait. The AV walked away from the door and back into the bathroom from 1:03:25 p.m. The camera footage, which was provided for this investigation, ended at 1:15:12 p.m. with the AV remaining in the bathroom.

The FM said that the prescription bottles should not have been left out for the AV to access. However, it was ultimately the AV’s choice to ingest the pills. The FM did not blame SP1 but was disappointed that the incident occurred at all and with the facility’s communication (e.g. the AV’s medical treatment and follow-up). In addition, although the facility had already been considering referring the AV to a different facility at the time, this incident did not help things and had a potential to prevent other facilities from accepting the AV in the future.

SP1 provided the following information:

· On August 27, 2024, SP1 picked up two of his/her own prescriptions from a pharmacy, Ativan and buspirone. SP1 typically stored his/her medications at his/her home; however, on this day, SP1 mistakenly left them in his/her car.

· On August 28, 2024, SP1 was scheduled to start work at 7 a.m. When s/he arrived, the prescriptions were still sitting on his/her front passenger seat. SP1 did not want to leave them in the car due to the projected hot weather that day so s/he put both prescription bottles in his/her bag. SP1 then went into work and locked his/her bag in the staff closet which s/he “always” did.

· At some point prior to noon, SP1 took his/her bag out of the closet for his/her breaktime. When s/he returned from break, s/he began doing routine paperwork at a dining table and hung his/her bag on the back of his/her chair.

· Around 12:10 p.m., SP1 brought the youth to the central dining room for lunch forgetting that his/her bag was in the dorm on the back of the chair. After lunch, the youth were escorted to school. When SP1 returned to the dorm, s/he discovered his/her bag had been left out and unattended. SP1 immediately locked the bag back in the staff closet. SP1 did not check the contents of his/her bag at that time.

· At some point later, the AV returned to the dorm from school and was acting “loopy and tired.” SP1 did not consider this might be related to the medications in his/her bag.

· At 3 p.m., SP1 prepared to leave for the day and got his/her bag out of the closet at that time. SP1 then noticed both prescription bottles were missing and told P2 “right away.”

· SP1 did not intend to leave his/her bag out and had never done anything similar previously.

Conclusion for Allegation One:

A. Maltreatment:

On August 28, 2024, SP1 left his/her bag unattended in the dorm, which allowed unsupervised and unrestricted access to the AV. SP1’s medications were in the bag, which were then also accessible to the AV. The AV ingested SP1’s medications and experienced symptoms including slurred speech, which prompted staff to take the AV to the emergency room. SP1 did not immediately notice his/her medications were missing or that the AV might have had access until s/he went to leave for the day.

Although the AV was ultimately unharmed, the AV had a history of substance abuse and suicidal ideation with at least one attempt. Therefore, there was a preponderance of the evidence that leaving harmful items, including medications accessible to youth and the AV, was a failure to supply the AV with necessary care and a failure to protect the AV from conditions that seriously endangered the AVs physical health when reasonably able to do so.

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

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.

SP1 was responsible for the AV’s care and supervision. SP1 received training on the facility’s policies and procedures and on the Reporting of Maltreatment of Minors Act.

SP1 was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which SP1 was responsible was “serious” maltreatment. SP1 was responsible for a single incident of maltreatment, which resulted in the AV requiring the care of a physician, including two liters of intravenous fluid.

SP1 was disqualified from providing direct contact services.

Allegation Two: The AV “threatened to vomit” on SP2 and in response, SP2 “swung” at the AV.

The facility’s policies and procedures stated, “The interaction between staff and the youth are the cornerstone to developing a physically and emotionally safe environment … Regardless of the time of day, [the staff person] is an adult model from whom the youth can learn and grow.”

At the outset of the investigation, information was provided that it appeared SP2 swung his/her fist at the AV on August 28, 2024.

SP2 provided the following information:

· At the time of the incident, August 28, 2024, around 9 p.m., SP2 was in the dorm helping youth with snacks and medications.

· The AV had just returned from the emergency room. “[The AV] wasn’t feeling well … [S/he] seemed still under the influence and very aggressive.” The AV followed various staff around and made “sexual” and “threatening comments” towards them. “I was one of [the AV’s] main targets.” SP2 repeatedly moved away from the AV but the AV kept returning or following him/her.

· At one point, SP2 was sitting in a chair in an open area of the dorm bedroom hallway. The AV was in a bean bag chair next to SP2’s chair. The AV abruptly stood and told SP2 that s/he was going to punch and vomit on him/her. SP2 immediately stood up in response. SP2 did not swing at the AV but “moved away … trying to create space as I didn’t know if [s/he] was going to punch me. That was a body reflex to protect myself. A natural reflex. I made no attempt at swinging. There was no swinging. I made no contact.” “I have a lot of experience in responding to incidents, but I can’t control my body reflex to protect myself.”

The faciilty’s camera footage was provided for the investigation and showed the following for August 28, 2024:

· At 9:02:05 p.m., SP2 sat on a wooden chair facing the bedroom hallway. The AV walked around SP2 into an alcove and sat in a bean bag chair facing SP2. SP2 remained looking down the hallway and appeared to be periodically engaging verbally with the AV.

· Between 9:06:05 and 9:06:55 a.m., the AV shook his/her upper body back and forth rapidly while curled up on the bean bag chair. SP2 remained sitting in the chair and occasionally glanced at the AV. At least once, the AV looked at SP2 and at one point, the AV repositioned his/her leg to not fall off the bean bag chair. At 9:06:56 a.m., the AV abruptly stopped shaking and immediately stood up walking towards SP2. [Note: Information was provided that the AV did not have a history of seizures. At the time of this incident and following, staff believed and determined the AV was “faking” a seizure. There was no information or signs or symptoms the AV experienced a seizure on August 28, 2024.]

· The AV took a few steps towards SP2. SP2 moved to stand with the AV standing over him/her. The AV lunged towards the back of SP2’s head. SP2 stood up fully and raised both of his/her arms while facing the AV. The AV stepped away and SP2 lowered his/her arms at 9:07:00 a.m. SP2 stood in place with his/her arms at his/her sides, no longer raised. The AV left the area. SP2 did not make any physical contact with the AV.

P2 and P3 each reviewed the camera footage. P2 said that SP2 was one of the “top de-escalation people” at the facility. P2 and P3 each had no concerns with SP2’s reaction to the AV and did not see SP2 swing at the AV. P3 said SP2 “flinched.” “[SP2] pulls [his/her] arm back and makes a fist and then stops … [SP2] didn’t swing or intend to swing … [S/he] didn’t even swing across [his/her] body at all.” SP2 did not make any contact with the AV.

Conclusion for Allegation Two:

Information was provided that on August 28, 2024, SP2 swung his/her fist at the AV. The AV did not remember the incident. SP2 said that the AV had threatened to punch and vomit on him/her, which caused SP2 to stand up and have a body reflex. SP2 denied swinging at the AV, and camera footage did not show SP2 swinging at the AV. P2 and P3 reviewed the camera footage and had no concerns with SP2’s conduct. SP2 did not make any physical contact with the AV. Given that there was no information to support that SP2 tried or intended to swing or hit the AV, there was not a preponderance of the evidence that SP2 swung at or hit the AV.

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

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (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:

Allegation One: The facility completed an internal review and determined that policies and procedures were adequate but not followed. The incident was not similar to past events with SP1 or the AV. “At this time, it appears the [bag] was left out by accident.”

Allegation Two: The facility completed an internal review and determined that policies and procedures were adequate and followed. The incident was not similar to past events with SP2 or the AV. “Based on camera footage, it did not reveal that [SP2] swung at [the AV].”

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

SP1 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 SP1 was responsible for maltreatment and the disqualification of SP1 are each subject to appeal.

Certification:

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

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


state: MN

facility_name: Nexus Gerard Family Healing

report_date: January 12, 2024

summary: CORRECTION ORDER

raw_content:
January 12, 2024

Michelle Murray, Authorized Agent

1111 28th St NE

Austin, MN 55912

RE:  Report No. 202305769

Nexus Gerard Family Healing

License No. 831080

Dear Michelle Murray:

CORRECTION ORDER

An investigation of Nexus Gerard Family Healing was completed regarding report number 202305769 which alleged violation of Minnesota Statutes, chapter 260E; Minnesota Statutes, chapter 245A; and Minnesota Rules, chapter 2960. This maltreatment allegation concerned neglect. The disposition of the investigation report is maltreatment not determined. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

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

Citation: Minnesota Statutes, section 2960.0050, subpart 1, item N.

Violation: The license holder failed to ensure that a resident’s (R’s) basic rights, including the right to courteous and respectful treatment, were followed.

Information showed that on July 5, 2023, during a behavioral intervention, a staff person (P) used language directed at the R that was not respectful to the R.

Corrective Action Ordered: Beginning immediately and on an ongoing basis, maintain compliance as required in this subdivision.

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

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Madelyn Gilbertson at Madelyn.Gilbertson@state.mn.us or 651-431-4585.

Sincerely,

Scout Peterson, Investigator

Office of Inspector General

Licensing Division

scout.peterson@state.mn.us

651-431-6578

Enclosure

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: CORRECTION ORDER

raw_content:
August 18, 2023

Michelle Murray

505 Highway 169 North, Suite 500

Plymouth, MN 55441

RE:  Report No. 202304093

Nexus Gerard Family Healing

License No. 831080

Dear Michelle Murray:

CORRECTION ORDER

An investigation of Nexus Gerard Family Healing was completed regarding report number 202304093 which alleged violation of Minnesota Statutes, section 260E, and Minnesota Rules, parts 2960.0010 to 2960.0120 (CRF). This maltreatment allegation concerned neglect. The disposition of the investigation report is maltreatment not determined. One violation was noted.

VIOLATIONS AND CORRECTION ORDERS

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

Citation: Minnesota Rules, chapter 2960.0080, subdivision 17, item A.

Violation: The license holder must report critical incidents of a serious nature that involve or endanger the life or safety of the resident or others to the commissioner of human services or corrections within ten days of the occurrence.

On May 11, 2023, eight youth were walking through a nature center and came to a flooding creek. Four youth went into the water and were caught in the current. The four youth and a staff person went through a culvert to get out of the current. The facility did not report an incident as required.

Corrective Action Ordered: Within 30 days from receipt of this order, submit a plan to your licensor explaining how you will maintain compliance in the future.

Submissions required as part of a corrective action ordered must be sent to your Licensor at:

Commissioner, Department of Human Services

ATTN: Madelyn Gilbertson

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Madelyn Gilbertson.

Sincerely,

Kimberly Huettl Anderson, Senior Investigator

Office of Inspector General

Licensing Division

651-431-6553

kimberly.huett.anderson@state.mn.us

Enclosure

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


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: 202301716

Date Issued: May 3, 2023

Name and Address of Facility Investigated:

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

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

License Number and Program Type:

831080-CRF (Children’s Residential Facility)

Investigator(s):

Judith Schwanke/Kim Anderson
Minnesota Department of Human Services
Office of Inspector General
Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
judith.schwanke@state.mn.us

651-431-4033

Suspected Maltreatment Reported:

It was reported that a staff person (SP) tackled an alleged victim (AV) to the ground and punched the AV in the face, causing a black eye.

Date of Incident(s): February 21, 2023

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 1, 2023; from documentation at the facility; and through nine interviews conducted with facility supervisor (P1), facility staff persons (P2, P3, P4, P5 and the SP), a family member (FM) and the AV.

The facility provided residential treatment to youth ages six through eighteen who struggled with their emotions, behaviors, and mental health. The facility provided therapy and mental health resources. The facility’s property was located off an interstate and off a frontage road. To the east of the facility was a golf course and between the golf course and the frontage road there was a chain link fence. On the day of the incident, the ground was covered with snow.

The AV’s Face Sheet showed the AV was 17 years old at the time of the incident. The AV’s Residential Treatment Plan stated the AV was artistic, loved animals and was social. The AV was diagnosed with attention deficit/hyperactivity disorder, major depressive disorder, disruptive mood dysregulation disorder, and an unspecified anxiety disorder. Staff persons helped the AV learn appropriate social skills and practice positive interactions and appropriate boundaries.

The facility’s Incident Report and Review, written by the SP, stated that on February 21, 2023, at 2:45 p.m., staff persons were called to respond when the AV walked away from the facility and towards the road. The AV crossed the golf course, jumped a fence, and ran towards the interstate. As the SP approached the AV, the AV threatened to hurt the SP. The SP attempted to place the AV in a hold and both the SP and the AV fell to the ground. The AV punched the SP repeatedly and when additional staff arrived, the AV was placed in a hold. The AV had a black eye, swelling around the eye, and cuts on his/her face from thorns on the ground. The incident ended at 3 p.m.

The facility’s Program Abuse Prevention Plan stated, “Regardless of the time of day, the youth care professional is an adult role model from whom the youth can learn and grow. As an adult role model, he/she establishes a trusting relationship with the youth. Through the trusting, therapeutic relationship, the youth feel a sense of security. When the youth feels secure with staff, growth can take place.”

The AV stated that on February 21, 2023, s/he ran toward the “bridge near the highway” because s/he no longer wanted to be at the facility. Near the bridge, the AV was “tackled” by the SP and fell to the ground landing on his/her back on snow and branches. The SP then punched the AV twice in the left eye and then other staff persons intervened so the SP could not punch the AV again. The AV did not receive medical treatment but had a black eye that lasted a few days.

The FM stated that s/he was told of the incident by P1 and the AV. The FM stated that the AV had a history of leaving the facility and staff persons were to follow the AV and try to keep the AV from endangering him/herself.

P2 provided the following information:

· On February 21, 2023, at approximately 2:30 p.m., P2 responded to a call for help from the SP because the AV was leaving the facility. P2, P4, P5 and the SP got into the van and drove near the golf course. P2 and P4 got out of the van and were moving toward the AV on foot while P5 and the SP drove to the frontage road. P2, P3, and P4 followed the AV through the golf course and then the AV “hopped” over the fence and was moving toward the frontage road. P2, P3 and P4 also “hopped” over the fence and followed the AV at a distance.

· The AV was near the frontage road, saw the van and then moved back toward P2, P3 and P4. The SP got out of the van and moved toward the AV. As the SP got close to the AV, the SP “charged” and “tackled” the AV. When the SP “tackled” the AV, the AV landed on his/her back with the SP on top of the AV. Then the AV hit the SP in the face.

· The SP responded by hitting the AV in the face with a closed fist. Within ten seconds, P2 held the AV’s right arm and P4 held the AV’s left arm, in an attempt to place the AV in a “supine” hold. During this time, the SP hit the AV in the face approximately three or four times more. The SP “scooted” down to restrain the AV’s legs, and as the SP was moving down the AV’s body, the SP hit the AV in the stomach.

· Once the AV was restrained, the SP got off the AV’s legs. P2 and P4 got the AV to a standing position and walked the AV to the van and P3, P4, P5, and the AV went back to the facility in the van. P2 and the SP walked back to the facility. While walking, the SP talked to P2 about “how to make this [the incident] look better on paper.” P2 did not respond to the SP.

· The AV left the facility at the time because s/he was “frustrated.” “Tackling” the AV did not need to happen because the AV was not trying to hurt him/herself at the time.

P3 provided the following information:

· On the day of the incident, when the AV left the facility, P3 followed behind the AV but gave space to allow the AV time to “cool down.” The AV then ran down the “driveway” and then ran into the golf course and running toward the interstate. P3 was trying to keep the AV away from the ramp onto the interstate and once P3 saw the van, P3 moved more toward the AV.

· While P3 was behind the AV, P3 saw a door to the van open and the SP jumped out and started running toward the AV. P3 then started running toward the AV and the SP and saw the SP dive toward the AV and then get up on his/her knees. P3 saw the SP bring up his/her fist and then down two times. P3 began to run faster and was not able to continue to watch the SP. When P3 arrived at the AV and the SP, the AV’s glasses were broken, and the AV had scrapes on his/her face and his/her left eye was swollen.

· The AV stated that s/he wanted to call the police and P3 asked the AV why. The AV replied because the SP had hit him. The SP denied hitting the AV.

· From training P3 received, P3 did not believe the SP should have tackled the AV. P3 believe the AV could have been placed in a hold or guided to where the staff persons wanted him/her to go.

P4 provided the following information:

· P4 followed the AV on foot through the golf course and over a fence toward the frontage road. P4 was attempting to get in front of the AV and guide him/her to the van. At this time, the AV turned and was running when the SP ran and tackled the AV. The AV hit the SP one or two times and then the SP hit the AV in the face three or four times with a closed hand.

· P4 grabbed the SP’s right arm to stop the SP from continuing to hit the AV and then P2 and P4 put the AV in a restraint hold. Once the SP was moved away from the AV, P2 and P4 were able to get the AV calmed and into the facility van.

· The SP told P4 that the AV ran at him/her with his/her fists balled and hit the SP. The SP also told P4 that s/he attempted to block the AV’s hits and if his/her hands were bloodied it was because s/he fell on the ice.

· P4 did not believe the SP should have tackled the AV. P4 stated there were enough staff persons present to “herd” the AV away from the road and to the van and the SP’s actions were not consistent with the techniques used at the facility.

P5 provided the following information:

· On the day of the incident, P5 heard the call for assistance and learned the AV was all the way down the driveway so P5 grabbed keys for the van. The SP and P2 were outside and got into the van while P5 drove. When the van was by the golf course, P2 got out and followed the AV on foot along with P3 and P4.

· The AV was running across the golf course, jumped a fence and was headed toward the frontage road. As the AV was moving up a slight incline toward the frontage road, the SP asked P5 to stop the van and P5 did so. The SP got out of the van, ran down the ditch, and tackled the AV to the ground.

· P5 could see P2, P3, and P4 moving toward the AV. P5 drove further down the road, turned around and came back and saw the other staff persons putting the AV in a hold. P5 exited the van to supervise the hold. P2 and P4 had the AV in a hold and the SP was holding the AV’s legs. The AV yelled that the SP had assaulted him/her and asked for the police to be called.

· The AV was escorted to the van and driven back to the facility. When back at the facility, P5 checked on the AV and the AV said s/he had been punched in the face multiple times. P5 said s/he did not see the SP punch the AV, but P5 saw redness and swelling around the AV’s left eye.

· P5 did not believe the tackle was necessary because in the past, the AV had stayed on the side of the road and had not entered or crossed the road and there were four staff persons around the AV.

P6 was interviewed by this investigator but was not involved in the incident and did not have information relevant to the allegations.

The SP provided the following information:

· On February 21, 2023, the SP heard a call that the AV had left the facility so the SP, P2 and P5 got into the van and started to drive toward the golf course. The van stopped on the frontage road and the SP got out.

· The AV then ran towards the SP with his/her hands in fists, so the SP ran towards the AV. As the AV was running, the SP attempted to put the AV in a hold, “almost like a tackle.” In doing so, both landed on the ground with the AV on the bottom, face down, and the SP on top. The AV “flipped over like lightning” and hit the SP in the face, causing a cut on the SP’s lip and causing a loose tooth. The SP stated s/he was “blocking” the AV’s “punches.”

· The SP stated that s/he stopped the AV from running toward the road because s/he did not want the AV to be hit by a car or truck.

· The SP denied hitting the AV. The SP said was blocking hits from the AV, trying to change the direction of the AV’s hands, and “shoving” the AV’s hands to the ground and that if s/he had any contact with the AV’s face, it was unintentional. The AV’s black eye could have been caused when the AV fell face first on the ground.

P1 provided the following information:

· On February 21, 2023, the AV had been “dysregulated” most of the afternoon and at approximately 2:40 p.m., the AV ran out of the facility, down the road, through the golf course, over the fence, and toward the frontage road.

· When the AV ran out of the facility, a call was made asking for assistance from other staff persons. Some staff persons followed the AV on foot while some, including the SP, followed in a facility van. P1 remained at the facility.

· After the incident, P1 saw that the AV’s left eye was swollen and developed into a black eye.

· P1 spoke to and/or had P2, P3, P4, P5, and the SP write a statement and each provided information that was consistent with the information each provided during their interviews. P1 said that staff persons should have waited until all staff were near the AV and then guide him/her back toward the facility. Staff persons could have placed the AV in a hold if s/he became aggressive.

Facility documentation showed that all staff persons interviewed for this investigation received training on the Reporting of Maltreatment of Minors Act. The SP was trained on the facility’s Program Abuse Prevention Plan on December 27, 2022.

Conclusion:

A. Maltreatment:

On February 21, 2023, the AV left the facility and was followed by five staff persons on foot and via the van. The AV was near a frontage road to an interstate as staff persons were nearing him/her. The AV, P2, P3, P4, and P5 provided consistent information that the SP ran toward the AV and tackled the AV to the ground. The AV, P2, and P4 stated that then the AV hit the SP and the SP punched the AV more than once in the face and in the stomach. P3 stated that s/he saw the SP’s arm move up and down as s/he ran to the SP and the AV and when s/he arrived the AV’s glasses were broken, and the AV had scrapes on his/her face and his/her left eye was swollen. P5 stated s/he did not see the incident but P5 was in the van turning it around at the time. Immediately after, the AV had scratches on his/her face, his/her glasses were broken, and his/her left eye was swollen and then developed into a black eye.

The SP denied hitting the AV and said that s/he might have unintentionally hit the AV in the face as s/he was attempting to block the AV from hitting him/her. However, given that the SP had reason to minimize his/her interactions for fear of repercussion; that the AV said the SP hit him/her; that P2, P3, P4, and P5 each saw the SP tackle the AV; that P2 and P4 each stated they saw the SP hit the AV in the face more than once; that P3 observed the SP’s arm move up and down and then the AV had an injury; and that immediately after the incident, the AV had a swollen and bruised eye and the AV’s glasses were broken, there was a preponderance of evidence that the SP’s actions were not accidental and caused injury to the AV.

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

In addition, given that P2, P3, P4, and P5 each stated that the AV was not a danger to him/herself or others at the time of the incident, the SP’s actions of physically intervening with the AV were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and there was a preponderance of the evidence that their was a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered his/her physical or mental health or safety.

Therefore, 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 and failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so.

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

When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors:

(1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care;

(2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and

(3) whether the facility or individual followed professional standards in exercising professional judgment.

The SP was trained on the Reporting of Maltreatment of Minor’s Act and the Program Abuse Prevention Plan.

The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because this was a single incident that met two definitions of maltreatment, but was serious because the AV sustained a black eye.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate and followed. The SP no longer worked at the facility.

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

The SP was notified that s/he was responsible for serious maltreatment and that any future background studies for facilities, programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal.

Certification:

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

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

doc_type: Maltreatment Finding


report_date: October 7, 2022

raw_content:
October 7, 2022

Michelle Murray, Authorized Agent

Nexus Gerard Family Healing

505 Highway 169 North

Plymouth, Minnesota, 55441-6447

License Number: 831080 (CRF)

Report Number: 202201129

CORRECTION ORDER

Dear Michelle Murray:

On June 27 and June 28, 2022, the Department of Human Services (DHS) conducted a modified licensing review and licensing investigation at your facility located at 1111 28th Street Northeast, Austin, Minnesota, 55912-6410. The modified licensing review and licensing investigation were conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and residential mental health treatment under Minnesota Rules, 2960.0580 through 2960.0700, and restrictive techniques standards under Minnesota Rules, part 2960.0710 (Rule CRF). As a result of this modified licensing review and licensing investigation, a correction order is being issued.

Reason for Correction Order

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

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

LICENSING VIOLATIONS

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

Postings

1. Citation: Minnesota Rules, part 2960.0050, subpart 3, item D.

Violation: A copy of the resident’s rights was not posted in the staff work station of each unit.

Corrective Action Ordered: This violation was corrected during the licensing review, no further corrective action is required.

Policies and Practices

2. Citation: Minnesota Rules, part 2960.0160, subpart 4, item A.

Violation: The license holder’s practice of giving required information about facility rules to residents did not meet requirements in the following ways:

a. The rules provided to residents upon admission did not include all of the rules and consequences used at the program. Daily shift reports documented use of “room programming” that was not included in the information provided to residents; and

b. The rules and consequences in resident handbooks varied by each unit and were inconsistent with those identified in the policy and procedure manual.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the facility rules provided to residents at admission meet all applicable requirements. Within 30 days receipt of this order, submit revised resident handbooks and a revised policy that demonstrates compliance.

3. Citation: Minnesota Rules, part 2960.0050, subpart 3, item A.

Violation: The license holder’s practice of providing basic rights information to residents within 24 hours of admission did not meet requirements. A copy of the basic rights information was not provided to residents.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that a copy of resident rights provided to the resident meets all applicable requirements. Within 30 days receipt of this order, submit documentation that demonstrates compliance.

Personnel Files

4. Citation: Minnesota Statutes, section 245A.041, subdivision 5.

Violation: Six of six personnel files reviewed for requirements governing background studies (personnel file numbered 1, 2, 5 and 14 through 16) did not meet requirements. There was no documentation of the first date the staff person began working in the licensing holder’s facility.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that background study documentation meets all requirements.

5. Citation: Minnesota Rules, part 2960.0080, subpart 14.

Violation: Eleven of thirteen personnel files reviewed for requirements governing ongoing training (personnel files numbered 1, 2, 6 through 10, 11 through 13 and 16) did not meet requirements. The files did not contain documentation to demonstrate that staff received ongoing training on emergency procedures at least every six months in 2021 and 2022.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that the provision and documentation of ongoing training meets all requirements. Within 30 days receipt of this order, submit documentation that staff identified above, who currently work for Nexus Gerard, have received emergency procedure training.

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

Resident Files

6. Citation: Minnesota Rules, part 2960.0070, subpart 4.

Violation: Five of five resident files reviewed for requirements governing admission procedures (resident files numbered 1 through 3, 5 and 6) did not meet requirements. Documentation contained the resident signature on a “Personal Property Waiver” that did not include the inventory of the resident’s property; the inventory was maintained in a separate electronic file.

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

7. Citation: Minnesota Rules, part 2960.0070, subpart 5, items A through C.

Violation: Six of six resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways:

a. The health screenings were not completed within 24 hours and did not include the following required components:

1. The resident’s current medications (resident files numbered 2 and 7);

2. The most recent physician’s and clinic’s name (resident files numbered 1 and 7), and address and telephone number (resident file numbered 1 through 3, 5 through 7); and

b. There was no documentation to show that the screening for sexually abusive behavior was completed (resident file numbered 1), or that a risk management plan was created (resident file numbered 5 and 6); and

c. There was no documentation to show the degree to which the family desires to be involved during the residents stay at the facility (resident file numbered 6).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that admission screenings meet all applicable requirements. Within 30 days, submit documentation for two resident admission screenings that demonstrate compliance.

8. Citation: Minnesota Rules, part 2960.0080, subpart 9, item D and subpart 14.

Violation: Three of five resident files reviewed for requirements governing program services did not meet requirements in the following ways:

a. There was no documentation to demonstrate chemical health education was provided to a resident who has had a problem related to inappropriate chemical use (resident file numbered 6); and

b. Emergency plans were not reviewed with residents at least once every six months (resident file numbered 2, 5, and 6).

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

9. Citation: Minnesota Rules, parts 2960.0600, item A, and 2960.0620, subpart 1, items A and B.

Violation: Six of six resident files reviewed for requirements governing treatment plans did not meet requirements in the following ways:

a. The treatment plan was not completed within 10 working days of admission (resident file numbered 7); and

b. The plan was not based on a diagnostic assessment (DA); a DA was not completed (resident file numbered 7); and

c. The treatment plan did not include the following required components:

1. A schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 3, 5 and 6); and

2. The use of psychotropic medication (resident file numbered 3); and

3. A description in observable and measurable terms of the symptoms and behaviors that the psychotropic medication is to alleviate (resident file numbered 2); and

4. The data collection methods used to monitor and measure changes in the symptoms and behaviors that are alleviated by the psychotropic medication (resident files numbered 1 and 2).

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

10. Citation: Minnesota Statutes, section 245A.65, subdivision 2, item b. Minnesota Rule, part 2960.0080, subpart 5, item D.

Violation: Three of four resident files reviewed for requirements governing service plan reviews did not meet requirements in the following ways:

a. There was no documentation to demonstrate that the interdisciplinary team reviewed and evaluated the individual abuse prevention plan (IAPP) as part of the service plan review (resident file numbered 6); and

b. There was no documentation to demonstrate the treatment team reviewed the use of time out as a part of the individual’s treatment plan (resident file numbered 1, 5, and 6).

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

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

11. Citation: Minnesota Rules, part 2960.0620, subparts 2, and 5, items A, B and D.

Violation: Four of four resident files reviewed for requirements governing psychotropic medication monitoring did not meet requirements. The resident file did not include documentation of the following:

a. Weekly monitoring for side effects, for the first six weeks after a resident is admitted with psychotropic medication (resident file numbered 6); and

b. A monthly medication review for the first six months of taking a psychotropic medication (resident file numbered 5); and

c. A quarterly medication review (resident file numbered 1, 2, 5, and 6); and

d. There was no documentation of data collected since the last review (resident file numbered 1); and

e. The status of the resident’s goals in the individual treatment plan (resident file numbered 1, 2, 5, and 6).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that psychotropic medication monitoring meets all requirements.

12. Citation: Minnesota Rules, part 2960.0620, subpart 7, item A.

Violation: Five of five resident files reviewed for requirements governing informed consent did not meet requirements (resident files numbered 1, 3, 5, and 6). Informed consent documentation did not include the following required components:

a. The diagnosis and level of severity of the symptoms and behaviors for which the psychotropic medication is prescribed; and

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

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding informed consent meet all requirements.

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

13. Citation: Minnesota Rules, 2960.0080, subpart 5, item D.

Violation: Three of three resident files reviewed for requirements governing time out procedures (resident files numbered 1, 5, and 6) did not meet requirements. Documentation reviewed in milieu notes and shift reports referenced multiple instances where time-out was used, but the documentation required following the use of a time-out was not completed.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding time out procedures meet all requirements. Within 30 days receipt of this order, submit documentation demonstrating all staff persons have been re-trained on the use of time-out and any related policies or procedures.

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

14. Citation: Minnesota Rules, 2960.0710, subpart 10.

Violation: Two of five resident files reviewed for requirements governing the administrative review of restrictive procedures (resident files numbered 5 and 7) did not meet requirements. The administrative review must be completed by someone other than the person who decided to impose the restrictive procedure or that person’s immediate supervisor. The administrative review completed did not identify who completed the administrative review.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements regarding administrative reviews meet all requirements.

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

15. Citation: Minnesota Rules, 2960.0090, subpart 1, items B and C, subpart 2 and 3.

Violation: Five of five resident files reviewed for requirements governing discharge procedures did not meet requirements in the following ways:

a. For the discharge of a resident who did not reach their treatment plan goals, documentation did not include:

1. How the license holder conferred with other interested person(s) to review the issues involved in the decision (resident file numbered 8); and

2. The involvement of interested parties in discussing the issues leading to the discharge and determining if additional strategies could permit the resident to stay in the program (resident files numbered 4 and 8); and

3. If the review indicated that the decision to discharge was warranted, the reasons for it and the alternatives considered or attempted (resident file numbered 8); and

b. The resident file did not contain a signed receipt of personal property (resident files numbered 3, 4, and 8).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that requirements governing No Eject and discharge procedures meet all requirements.

Repeat Violation: The license holder was cited for a similar violation in correction order dated June 16, 2020.

16. Citation: Minnesota Rules, part 2960.0190, subpart 1, item A.

Violation: Two of two resident files reviewed for requirements governing transition services plans (resident files numbered 7 and 8) did not meet requirements. There was no documentation to demonstrate that a transition services plan was completed prior to the residents release from the program.

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

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

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

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

2. By mail to:

Commissioner, Department of Human Services
ATTN: Madelyn Gilbertson
Licensing Division
PO Box 64242
St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding this Correction Order, please contact Maddy Gilbertson, Senior Licensor at 651-448-3583, as soon as possible.

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer

http://www.dhs.state.mn.us/licensing

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


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: 202604841

Date Issued: July 8, 2026

Name and Address of Facility Investigated:

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

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

License Number and Program Type:

831080-CRF (Children’s Residential Facility)

Investigator(s):

Beth Virden
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
beth.virden@state.mn.us

651-431-6572

Suspected Maltreatment Reported:

It was reported that a staff person (SP) did not intervene in a manner necessary to prevent youth from continuously “bullying” an alleged victim (AV) for around two hours.

Date of Incident(s): May 18, 2026

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 3, 2026; from documentation and camera footage at the facility; and through six interviews conducted with the AV, a facility youth (Y1), the AV’s guardian (G), facility staff persons (the SP and P1), and a supervisory staff person (P2).

The facility was a campus with multiple buildings that provided residential treatment services to youth, ages 9 to 18, who needed emotional, behavioral, and mental health support. The facility provided supervision, education, recreation, and therapy, and had more than one dormitory (dorm) for the youth.

The AV’s support plans stated that on May 1, 2026, the AV moved into the facility seeking help to regulate his/her emotions and minimize unsafe- and disruptive-behaviors. At the time of the incident, the AV was 14 years old.

Y1 said that on May 18, 2026, s/he and some other youth “had enough” of the AV’s behaviors, which included “lying” and “bothering” others. Y1 and the other youth chased the AV around the dorm and sprayed water on him/her. Y1 said that the SP was present but did not do anything to stop them and instead, the SP told them, “Just don’t get me wet.”

The AV said that the SP was “just standing there,” and told the youth, “I bet you can’t catch [the AV],” which prompted them to chase him/her. At least once, the AV told the SP, “Tell them to stop … Get them to stop,” but the SP did not do so and instead told the youth, “Just don’t get me involved.” “A couple of times,” a youth punched the AV and one time, a youth struck the AV with a skateboard, but the SP did not do anything to stop them. Eventually, the youth just stopped and went to their respective bedrooms for the night. There was another staff person (P3) present, but s/he was “somewhere else” in the dorm. The AV did not sustain injuries.

The facility’s camera footage from inside the dorm provided the following information:

· [Note: The camera footage did not have audio, or a clock. The times listed below were provided by the facility’s Internal Review and Incident Report and/or estimated times.]

· On May 18, 2026, the SP and P3 worked in the dorm with 16 youth, including the AV and Y1. P3 was initially present on the camera footage but was not seen again until the end of the footage and incident. The SP was the sole staff person present for the duration. Throughout the footage, there was a lot of activity with youth running around and/or pretending to punch or kick each other. One youth carried a skateboard and pretended to swing the skateboard at others. There was no physical contact during these incidents.

· However, there was physical contact when it came to the youths’ interactions with the AV. At the start, or around 6:30 p.m., the AV was going in and out of his/her bedroom or bathroom and there were youth in the hallway. [Note: P2 said that the youth were kicking the bathroom door with the AV inside and going in and out of the AV’s bedroom. The conduct was not clear on the footage to this investigator.]

· Around 7:30 p.m., the AV ran to the dorm exit door followed by four youth, including Y1. One youth held the AV’s arms behind his/her back while the others gathered around in a circle. The SP was standing nearby and appeared to say something to the youth but did not approach them. The youth let go of the AV and the AV ran down the hallway followed by four or five youth, including Y1. The SP did not follow but sat in a chair facing the hallway.

· At one point, the AV ran past the SP, who was still sitting down, and stopped within five to ten feet of the SP. Y1 and four or five youth surrounded the AV, and Y1 swung his/her fist downward striking the top of the AV’s head. The AV put his/her hands on top of his/her head, pointed at the SP, and appeared to say something. The SP looked at them but did not stand up or appear to say anything.

· Around 8 p.m., four or five youth cornered the AV by the dorm exit door and two youth made humping motions in front of the AV, and another swung a skateboard at the AV but did not appear to make physical contact. At this point, the SP stood up and walked towards them and the youth walked away. The AV opened the exit door and the SP quickly stepped in front of him/her and pushed the AV backwards away from the door. The SP was holding his/her two-way portable radio (walkie-talkie) during this time. Four or five youth, including Y1, ran up quickly and surrounded the AV and the SP, who stood next to each other in the corner. The SP held out his/her arm and appeared to tell the youth to back away. A youth approached with a water pitcher and the SP grabbed the pitcher and waved his/her hand back and forth in a gesture commonly known to mean, “No.”

· The AV appeared to be repeatedly trying to step behind the SP, but the SP kept his/her hand on the wall, which prevented the AV from going behind him/her, and the SP was leaning against the exit door.

· Around 8:09 p.m., the SP’s head was turned focusing on a youth off to the side when another youth approached and quickly punched the AV’s stomach and then walked away. The AV bent over and grabbed his/her stomach. The SP did not react or appear to see what happened. The SP then looked down at his/her watch and Y1 sprayed water from a water bottle into the AV’s face. The SP did not move or appear to say anything to Y1. Y1 then repeatedly sprayed water at the AV and the SP appeared to step out of the way from getting wet. The AV’s shirt was visibly wet. The SP used his/her own shirt to wipe the SP’s face at various points as though it too was wet.

· At various points, the SP appeared to shake his/her head “no,” at the youth and more than once, waved his/her hand back and forth at the youth indicating “no.”

· Around 8:13 p.m., P1 arrived and walked into the dorm and at that point, everyone stopped what they were doing but continued standing in a circle by the door. P1 walked around and interacted with some of the youth. Y1 sprayed water at the AV, and the SP looked at Y1 and then pointed at him/herself (the SP) as though indicating that Y1’s water spray hit the SP.

· Around 8:15 p.m., a youth walked up to the AV and held a skateboard sideways in front of the AV’s groin. The youth’s actions were not fully visible on the camera footage. The SP looked down at the skateboard and then the AV appeared to scream and cover his/her groin with his/her hands. The SP put a hand on the youth with the skateboard and the youth stepped away. The SP did not move or appear to say anything. P1 had his/her back turned at that point and did not appear to see what happened.

· A youth then approached and kicked the AV in his/her groin, and the AV bent over and grabbed his/her groin. The SP appeared to be watching this happen but did not move or say anything. P1 was talking and pointing in another direction when this occurred but looked when the AV bent over. P1 watched the youth walk away and then Y1 sprayed water at the AV and P1 said something to the youth. The SP put a hand on the AV and directed him/her to walk and Y1 followed while repeatedly jumping up and down next to the AV and spraying him/her with water. The AV removed his/her shirt which appeared soaking wet, and the SP and the AV walked off camera view. Other youth gathered around P1 to talk and then s/he left, and the camera footage ended. P1 was in the dorm for about four minutes.

P2 provided the following information:

· The AV was younger than the other youth and had “a lot of energy” and lacked impulse control. The older youth and the AV bantered back and forth, and staff had been intervening and managing the interactions without incident.

· P2 watched the camera footage and saw that the SP did not make attempts to step between the youth or redirect them away from the AV. When the AV tried to leave the dorm, the SP stopped him/her from leaving. At times, the AV was laughing and appeared to be trying to keep things “lighthearted,” but the AV also looked “distressed” and was repeatedly trying to get away.

· P2 said that the SP should have done more to stop the youths’ “bullying” of the AV. The SP could have radioed to another dorm to ask for additional staff or ask that the AV go to another dorm until bedtime. The SP could have let the AV leave the dorm and sit on the couch directly outside the door. The SP could have stepped between the youth and told them to leave or go to bed. P2 said, “I could go on with options for a while” on what the SP could have done but did not.

· On May 19, 2026, P2 gathered the youth for a group meeting to talk about bullying and what happened the night before. Y1 was not present for the meeting. During the meeting, more than one youth said that the SP did not do anything to stop them and instead told them, “Just don’t get me wet.” Later, P2 met individually with Y1, who said that the SP told them, “I bet you can’t catch [the AV],” which was what prompted them to chase the AV.

· P3, who was also working in the dorm, told P2 that s/he was on the other end of the hallway watching the youth in his/her vicinity, and although P3 saw youth running around by the SP, the youth were laughing and so P3 did not believe s/he needed to intervene. P2 said that the camera footage showed P3 walking in the hallway up to the bathroom area but not past the bathrooms. [Note: It was not possible to see the dorm exit door from the hallway bathroom area and there was no information that any physical contact occurred in any other locations, but the dorm exit area.]

P1 said that on May 18, 2026, at an unknown time, s/he walked into the dorm to deliver an item to a youth. P1 immediately sensed that “something was off,” but no one seemed angry, and no one said anything or showed “signs.” The SP was standing by the dorm exit door and did not say anything to P1. P1 saw Y1 spray water from a water bottle at the AV. The SP did not say anything to Y1 about this, and the AV did not say anything in response. P1 did not work in the AV’s dorm or with the age group or gender in the dorm and so did not know what the culture was like or if s/he should intervene given that the SP was standing right there among the youth. P1 was in the dorm for about five minutes, and when s/he left, s/he emailed a supervisor with his/her observations.

The SP provided the following information:

· On May 18, 2026, the AV was acting “squirrely,” which was “normal” for him/her. The AV was younger than the other youth and had a history of being “extremely antagonistic” and liking to “stir the pot.”

· The AV “antagonized” Y1 and the “older youth” and then ran away from them. The SP told the AV that s/he was a fast runner and that the AV should join a track and field team. The SP did not say anything to the other youth about the AV’s speed and did not “challenge” them to catch the AV.

· Y1 and other youth filled their water bottles and sprayed water at the AV as the AV ran away. The SP told them, “Stop this,” and “I’d really rather not get wet,” but they did not stop.

· The AV ran toward the dorm exit door and made comments about running away and jumping from a nearby bridge to die by suicide. The SP moved to block the AV from leaving the dorm. The SP said that there was a youth from a different dorm, at that same time, who was actively running away and so a lot of staff were preoccupied following that other youth. There was a limited number of available staff who would be able to respond if the AV ran.

· While standing by the door, the older youth gathered around the SP and the AV, and the AV hid behind the SP. More than once, the SP told the AV, “Stay behind me.” More than once, the SP told the older youth, “Leave [the AV] alone … Back up … Stop spraying water,” but the older youth “refused to listen.” The SP told the AV to go to his/her bedroom, but the AV said that s/he was not going if the older youth were not going to their respective bedrooms too. At one point, when the SP was focused on someone else, a youth “jabbed” their skateboard towards the AV. The SP asked the AV if s/he was okay and the AV said that the skateboard did not hit him/her.

· The SP said that they were in a “standoff,” and the SP was focused on keeping the AV safe. The SP was unable to call for additional staff help because when s/he moved quickly to block the exit door, s/he forgot to grab his/her “walkie” (two-way portable radio) from the desk. The SP said that s/he was supposed to keep his/her walkie close by but had removed it from his/her pocket to sit comfortably at the desk. The SP said that at this time of day, the dorm was typically “mild” as the youth were getting ready for bed.

· Twice, the SP yelled for P3 who was on the other side of the dorm, but P3 did not appear to hear the SP. The SP said that staff typically “split the dorm in half” with a staff staying on either side; the youth could go between the sides and staff were supposed to pay attention and help on either side as needed. The SP believed that P3 was most likely distracted by his/her cellphone and not paying attention to what was happening. [Note: P3 later told the SP that s/he did not hear the SP’s call for help. P3 told the SP that s/he saw youth running around and when they were within range of P3, s/he told them to stop running.]

· At one point, P1 walked past the dorm and waved at the SP and the youth, but s/he did not enter the dorm. P1 appeared to be doing something or talking to someone and so the SP could not signal him/her to help. Eventually, the older youth backed off and later apologized to the SP and the AV.

· The SP said that the facility never provided any training about what to do in a bullying situation.

· The SP believed the allegations were made against him/her (e.g., challenging the youth to catch the AV and not intervening) because P2 and other administrators told the youth that due to the incident, they would have their privileges “paused,” which prompted the youth “to point their fingers at” the SP.

The G said that s/he did not have concerns with the facility’s overall care and supervision but that the AV had a history of struggling to acclimate to new settings.

The facility’s Handle with Care policies and procedures stated that all staff were trained to intervene in a manner necessary to disrupt escalating tension. Staff were to respond in a calm and unafraid manner and to be firm, fair, and consistent without being intimidating. Staff were to listen to the youth, encourage assertiveness but not aggression, and offer alternative choices. Staff might need to physically intervene to protect a youth from youth-on-youth aggression.

The SP’s job description stated that the SP’s responsibilities included:

· Serving as a role model to youth by communicating and interacting in a manner that was professional.

· Ensuring compliance with all safety policies and procedures.

· Remaining cognizant of each youth’s trauma triggers and adapting interactions accordingly.

· Engaging in trauma-informed, strength-based therapeutic interventions with youth while maintaining appropriate boundaries.

Facility documentation stated that the SP, P1, and P2 received training on the facility’s Handle with Care policies and procedures and on the Reporting of Maltreatment of Minors Act.

Conclusion:

A. Maltreatment:

On May 18, 2026, for around two hours, more than one youth chased the AV around the dorm, sprayed the AV with water, and punched and kicked the AV. The SP was present throughout the incident and although the SP appeared to say things to the youth or hold up his/her arm to block the youth, the SP’s attempts to intervene were not adequate and ineffective at stopping the conduct. Camera footage showed the SP looking on as a youth physically aggressed towards the AV, but the SP did not move between the youth or make any obvious or meaningful attempts to redirect the youth or protect the AV.

Given that the SP did not intervene to protect the AV as multiple youth chased him/her, sprayed him/her with water, and physically assaulted the AV including punching the AV in the stomach causing the AV to bend over and grab his/her stomach and another occasion when the AV was hit with a skateboard in the groin appearing to make the AV scream and cover his/her groin with his/her hands, there was a preponderance of the evidence that there was a failure to supply the AV with necessary care required for the AV’s physical or mental health and a failure to protect the AV from conditions or actions that seriously endangered the AV's physical or mental health when reasonably able to do so.

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

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.

Regarding P1:

P1 arrived in the dorm at a point when the incident had been ongoing for over an hour. P1 was in the dorm for about four minutes and was not familiar with the youth and did not see or hear anyone asking for help. P1 felt there was “something off” but said that the SP was standing right there among the youth and had been prior to P1’s arrival. After P1 left, s/he emailed a supervisor about his/her observations. Given the situation and limited time for P1 to fully observe what was transpiring, P1’s responsibility was mitigated.

Regarding P3:

There was no information P3 was present for or witnessed any physical aggression towards the AV. P3 told P2 and the SP that s/he saw the youth running around but did not believe there was a need for him/her to intervene given that the SP was present. It was typical for the dorm to be split in half and for there to be a staff on either side. P3 said that s/he did not hear the SP call for help, and the camera footage did not show the SP yelling out at any points. Therefore, P3’s responsibility was mitigated.

Regarding the SP:

On May 18, 2026, the SP was responsible for the AV’s care and supervision. The SP was working on the side of the dorm where the AV was located and the incidents occurred. The SP received training on the facility’s Handle with Care policies and procedures and on the Reporting of Maltreatment of Minors Act. Although the SP said that the facility did not provide training about what to do in a bullying situation, the Handle with Care policies and procedures provided information about disrupting escalating tension and intervening to prevent client-on-client aggression.

Although the SP said that s/he was in a “standoff” and did not have his/her walkie to call for help, the camera footage showed the SP holding his/her walkie. The SP also said that P1 never entered the dorm and so the SP could not ask P1 for help, but P1 and the camera footage showed P1 entering the dorm and staying for about four minutes. P1 and the camera footage provided consistent information that the SP did not say anything to P1 or indicate that s/he needed help. In addition, the AV and Y1 each said, and other youth told P2, that the SP did not make any attempt to stop the youth and instead made comments that prompted the youth to chase the AV. Therefore, the SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. It was a single incident of maltreatment failing to intervene over the single period of time, for which the AV did not sustain a serious injury which reasonably required the care of a physician whether or not the care of a physician was sought.

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report.

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The facility provided additional training to all staff to ensure that youth-on-youth bullying did not occur and that staff were prohibited from encouraging, facilitating, or participating in any action that involved youth-on-youth aggression.

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

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

Certification:

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

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