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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: 202310093

Date Issued: May 9, 2024

Name and Address of Facility Investigated:

Newport Academy
1726 7th Ave S
St. Cloud, MN 56301

Disposition: Maltreatment determined as to neglect of the alleged victim by a staff person. Maltreatment not determined as to sexual abuse.

License Number and Program Type:

1108472-CRF (Children’s Residential Facility)

Investigator(s):

Kim Anderson/Van Mulheron
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-6592

Suspected Maltreatment Reported:

It was reported that a staff person (SP) kissed an alleged victim (AV) and sat underneath a blanket with the AV.

Date of Incident(s): On an unknown date prior to November 23, 2023

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

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

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 January 17, 2024; from documentation at the facility and law enforcement records; and through 13 interviews conducted with six supervisory and administrative staff persons (P1-P6), six staff persons (P7-P11 and the SP), and the AV’s family member (FM). The AV was interviewed by a Law Enforcement Officer and that information is included below.

The facility was a residential treatment center for youths ages 12-18 years with substance abuse and mental health concerns. In addition to providing treatment and counseling, the facility had a gym in the basement for residents to use with supervision. The gym had a stage area and staff only restrooms. The facility had six cottages where residents lived. The AV resided in a cottage and upon entry into that cottage was a kitchen. Past the kitchen, were tables for dining and activities and to the right of the tables was a hallway. In the hallway, on the left was a living room which had a television, chairs, sofas, and blankets and on the right side, was a door to a staff office and stairs that lead up to the residents’ bedrooms. In the hallway upstairs, between the bedrooms were two desks where staff persons stayed to supervise the residents overnight. There was a hallway outside of the cottage that connected it to other parts if the facility.

The AV’s Client Information stated that at the time of the incident the AV was 16 years old and diagnosed with major depressive disorder and substance use disorder. The AV enjoyed hunting and fishing. The AV “struggled to build and maintain healthy relationships, and one of his/her goals at the facility was to develop healthy relationship skills and friendships.” The AV resided at the facility between September 17 and December 2, 2023.

The law enforcement report provided the following information:

· On November 28, 2023, at 7:26 p.m., the SP called law enforcement because s/he was having suicidal thoughts and had taken an overdose of medication with alcohol. The SP said that s/he was “fired” from his/her job for “being in a relationship with an underage client,” “kissing an underage client,” and/or “performing oral sex on a 16- year-old [fe/male] client.” (Note: There was approximately a nine-year age difference between the SP and the AV.) The law enforcement officer was unable to obtain additional information due to the SP’s level of intoxication and the SP was taken to a hospital.

· A few hours after the SP was admitted to the hospital, the SP provided a statement to a law enforcement officer. The SP stated that in October 2023, after the SP ended a relationship with a community person (CP) unrelated to the facility, s/he and the AV “expressed feelings” for each other and for approximately three weeks the SP and the AV “kissed” each other “daily.” Once in late October, the SP and the AV were kissing in the gym area and the AV asked to go into the staff only bathroom with the SP. They went into the bathroom and the SP performed oral sex on the AV for about a minute but stopped because they were afraid of getting caught. The SP said the relationship with the AV included kissing and passing notes to each other. They continued the relationship and would take walks and pass notes. The relationship continued until about one week prior when the SP was transferred to work with other clients. The SP was then suspended while the facility looked into concerns regarding the SP’s interactions with clients. The SP also said s/he had notes in his/her purse that were from the AV, but they were not collected at the time of the SP’s statement.

· On November 29, 2023, a law enforcement officer contacted the facility and spoke to P2. P2 stated that the facility had received information from the CP that the SP had “feelings” for a client at the facility.

· On December 1, 2023, a law enforcement officer went to the facility and spoke to P2. At that time, P2 said that there was a recent incident where the SP was seen underneath a blanket with the AV in a group setting. P2 said the SP was moved to a different cottage after the incident and that the SP also requested to be moved to a different cottage.

· The law enforcement officer also talked to P1. P1 stated that around November 23, 2023, P7 contacted P1 and told P1 the SP had “feelings” for clients. P1 then met with the SP who “indicated [s/he] was struggling to maintain boundaries with [fe/male] clients. On November 28, 2023, P1 again met with P7 who had screenshots of message where the SP referred to kissing the AV.

· The law enforcement officer and P2 met with the AV. The AV denied “feelings” for the SP and denied that they had a “romantic relationship.” The AV said s/he “kissed [the SP] once” and they wrote notes to each other that were usually “have a good day” or something “similar.” The AV no longer had the notes as they were thrown away. The AV denied any sexual contact with the SP or that the SP performed oral sex on him/her. The AV “was emotional during the interview, remained composed but was crying tears throughout.” The AV “strongly denied [s/he] was lying to protect [the SP] and insisted [s/he] was telling the truth.”

· On December 5, 2023, the law enforcement officer talked to P7. P7 said that the SP told him/her that s/he “had feelings” for the AV but that “nothing had happened between them.” P7 also text messaged the CP who told P7 that s/he had seen text messages between the SP and the AV that talked about the SP kissing the AV.

· On December 12, 2023, the law enforcement officer talked to the CP. The CP stated that s/he saw messages the SP had sent that talked about “having a crush on [the AV] and that [s/he] had kissed [the AV].” The CP provided the text messages to law enforcement who documented that the messages “were consistent with” the CP’s information.

· On December 21, 2023, in a follow-up interview, the SP did not recall talking to law enforcement officers while in the hospital. The SP said s/he had “feelings” for the AV and that they “kissed.” The SP denied having oral sex or any other “physical contact besides kissing” with the AV. The SP said that at time s/he was off his/her prescription medications at the time which affected his/her behavior.

· The case was sent to the county attorney’s office for review of potential charges of Criminal Sexual Conduct 3rd Degree-Position of Authority.

P1-P11 and text messages provided the following information:

· P1 and P2 provided information that was consistent with the law enforcement report that on November 23, 2023, P7 called P1 with information that the SP had “feelings” for the AV. P1 spoke with the SP and the SP said, “I do admit that I have had some poor boundaries recently.” P1 then called P2. P1 and P2 were aware of another incident involving the SP and the AV being under a blanket together and they decided to move the SP to another cottage away from the AV with the understanding that the SP was not allowed near the AV.

· P10 said that s/he had not seen the SP or the AV under a blanket with each other but, in October or November 2023, s/he noticed “odd” interactions between the SP and the AV. P10 saw the AV sitting “too close” to the SP once or twice a shift when P10 worked with the SP. The SP and the AV sat “too closely” in the living room several times while sharing a foot stool, and upstairs near the bedrooms while listening to music on a laptop they were “almost touching.” P10 also saw the SP and the AV on the gym stage sitting next to each other “too closely” listening to music on the SP’s phone and whispering to each other. P10 told P5 about the incidents to P5 and then later told P4.

· P8 worked with the SP on an unknown evening in October or November 2023, during a movie night. P8 was in the dining room area and the SP was in the living room. P8 conducted a 15-minute headcount check to make sure all the clients were accounted for and when P8 walked into the living room s/he saw the SP and the AV sitting closely together underneath a blanket. The next day P8 told P4 and P6 about what s/he saw.

· P9 said that on an unknown evening prior to the AV’s bedtime when they were upstairs, s/he saw the AV sitting closely next to the SP whispering to each other. On November 20, 2023, P9 saw the SP and the AV sitting “too close” to each other in the living room. P9 said that the SP seemed too “favorite” the AV.

· P5 said that s/he walked into the living room and saw the SP and the AV sitting closely together, like “a couple,” watching a video with the rest of the clients. P5 turned off the video because it contained “inappropriate” media content that was not allowed by the facility and then sent the clients upstairs to get ready for bed because it was after curfew. P5 then spoke with the SP about respectful boundaries with the AV and that it concerned P5. The SP replied, “I know I get it, I get it” and apologized to P5. P5 then logged the incident and documented his/her conversation with the SP. (P5 was not able to provide this investigator with any documents regarding his/her conversation with the SP.) On November 20, 2023, at 11:20 p.m. P5 received a text message from P9 regarding “unhealthy boundaries” between the SP and the AV and the SP was removed from the AV’s cottage within the next few days.

· The text message between P5 and P9 said the following:

o P9 “[the AV] loves taking walks with [the SP]. They are on another one now…between painting [his/her] nails and these before bedtime walks. Something is rubbing me the wrong way.”

o P5 “[AV] seriously needs to stop.”

o P9 “More like [SP] might need to set some boundaries”

o P5 “I’m mad at P4 for not switching [him/her] to another cottage”

· P4 and P6 provided consistent information that on an unknown date in November they received a lead shift report about an incident when the SP was under a blanket with the AV. P4 said that s/he had “limited contact” with the SP, but had no prior concerns and was not aware of any other incidents between the SP and the AV other than long evening walks between the SP and the AV. P4 held a meeting with staff persons and a separate meeting with clients from the cottage about “boundaries.” P4 told staff persons and the clients that they were not to share blankets or sit next to each other on the couches. P6

said that the information provided did not include any physical contact, so the decision was made to complete “boundary coaching” with the SP and move the SP to work with different clients.

· P7 spoke with the SP on an unknown date prior to Thanksgiving and the SP told P7 that s/he had “feelings” for the AV. P7 told the SP to remove him/herself from the client “ASAP” and to talk to his/her supervisor within the next couple of days. On November 23, 2023, P7 told P1 what the SP said about having “feelings” for the AV. On an unknown date after Thanksgiving, P7 was contacted by a mutual friend of P7 and the SP who told P7 that s/he saw a text message on the SP’s phone that said that s/he had “feelings” for the AV and that the SP had “kissed” the AV. P7 told P5, and they told P1-P3 and P6. P1-P3 then decided to remove the SP from the facility while they conducted an investigation.

· P3 said that on an unknown date after Thanksgiving, P1 and P2 told him/her that the SP had “feelings” towards the AV. P3 said that s/he was aware that the SP and the AV shared a blanket and that the SP had received “counseling” from other staff members.

· P11 worked with the SP but was not aware of the allegations.

· Prior to this incident P1-P4 had no prior concerns about the SP’s interactions.

· P1-P11 provided consistent information regarding professional boundaries between clients and staff persons. Staff persons were to keep relationships work related, there was to be no touching clients unless absolutely necessary, staff persons should be an arm’s length away from clients, were not to share personal information with clients, and were not contact clients outside of work.

The SP provided the following information:

· The SP said that s/he worked with the AV for about two and half months, talked to the AV more than other clients, and “kind of” developed a “relationship” with the AV. The SP. There were a few times when the AV was talking about his/her parent and was “sad” and other times the AV was “upset” and the AV hugged the SP, so the SP hugged the AV back.

· On an unknown date one evening in the living room, the SP and some clients were watching a movie. The SP was sitting on a couch next to the AV when the AV took a blanket and covered both the SP’s and the AV’s legs. The SP “let it happen” and did not remove the blanket or him/herself from the area. The SP continued to sit next to the AV until the movie ended. The SP said s/he also spent time alone with the AV in the gym and on walks in the hallway that lasted about ten minutes.

· On an unknown date in November, the AV told the SP that s/he had “developed feelings for me” and the AV kissed the SP on the mouth and the SP kissed the AV back. The SP said that they were in the hallway in front of the staff office and that no one else saw them. The SP said that there was only the “one kiss” and there was no other sexual contact between them. The SP denied having performed oral sex on the AV.

· On an unknown date around Thanksgiving 2023, the SP requested to be transferred to another cottage because, “I knew what I did was wrong and if I stayed over there, I didn’t want anything else to happen.” The SP said that during the time s/he was not taking his/her mental health medications and “knew it wouldn’t be good for me to stay over there.”

· The SP said that staff persons were to have no physical contact with clients and “the most you could do was a high five.”

· The SP stated that no supervisory staff persons spoke with him/her about his/her interactions with the AV.

The FM said that s/he was not made aware of any concerns about the AV until two days prior to the AV’s discharge. Prior to being informed of the incident, the AV had never mentioned the SP to the FM and had not “shared” much information with the FM but had been talking with his/her therapist. The FM was happy with the facility and had no prior concerns.

The facility’s Code of Conduct stated that all staff persons must “maintain a professional relationship with clients,” “not become romantically or sexually involved,” “not engage in any type of relationship including electronic communication via email, Facebook, SnapChat, Instagram...” and there will be “zero tolerance for sexual contact with clients or engaging in conversation of flirtatious nature or sexual innuendo.”

Facility documentation showed that P1-P11 and the SP were trained in the Maltreatment on Minors Act and the facility’s Code of Conduct prior to the incident.

Conclusion

A. Maltreatment:

Information from P5 and P8-P10 was consistent that they saw interactions between the SP with the AV that were not within the scope of appropriate boundaries between a staff person and a client. (Note: There was a nine-year age difference between the SP and the AV.)

Regarding sexual abuse:

Information from the AV and the SP was consistent that the SP and the AV kissed at least one time and likely “daily.” On November 28 and/or 29, 2023, the SP told law enforcement officers twice that s/he had performed oral sex on the AV. However, on December 21, 2023, the SP said s/he did not recall talking to law enforcement officers while in the hospital and denied having oral sex or any other “physical contact besides kissing” with the AV.

Although the SP might have been freer to provide accurate information while under the influence of substances and that s/he had reason to minimize his/her actions for fear of repercussions, given that the AV denied having sexual contact with the SP and that kissing did not meet the definition of sexual abuse, there was not a preponderance of the evidence whether the SP and the AV had sexual contact.

It was not determined that sexual abuse occurred (the subjection of a child by a person responsible for the child’s care, by a person who has a significant relationship to the child, as defined in section 609.341, or by a person in a position of authority, as defined in section 609.341, subdivision 10, to any act which constitutes a violation of section 609.342 – 609.3451 [criminal sexual contact in the first through fifth degree].

Regarding neglect:

Information was consistent that the SP sat too close to the AV on multiple occasions in the living room, gym, and upstairs by the bedrooms. On November 20, 2023, P5 walked into the living room and saw the SP sitting “closely” on a couch next to the AV like “a couple.” P5 then spoke with the SP about respectful boundaries with the AV told the SP that it concerned him/her. The SP replied, “I know, I get it, I get it” and apologized to P5. P8 worked with the SP on an unknown evening during movie night and saw the SP and AV sitting closely together underneath a blanket.

On a date prior to November 23, 2023, the SP told P7 that s/he had “feelings” for the AV. Then on a date prior to November 28, 2023, P7 was told by a mutual friend that they saw messages from the SP that the SP had “feelings” for the AV and “kissed” the AV.

Although the AV denied “feelings” for the SP and denied a “romantic relationship” with the SP, the SP’s told law enforcement on different occasions that s/he was “in a relationship with an underage client,” that s/he and the AV expressed “feelings” for each other, and that s/he had “feelings” for the AV; and the SP told this investigator that s/he “kind of” developed a “relationship” with the AV and that the AV told the SP that s/he had “developed feelings” for the SP. In addition, information from the AV and the SP was consistent that the SP and the AV kissed at least one time and likely “daily.”

The AV was at the facility for supports regarding his/her substance use and mental health disorders. The AV’s Client Information stated that the AV “struggled to build and maintain healthy relationships, and one of his/her goals at the facility was to develop healthy relationship skills and friendships,” so it was reasonable that the AV would likely continue to need supports to develop and maintain the necessary life and social skills to maintain and build healthy relationships. The SP’s interactions with the AV, who was 16 years old and nine years younger than the SP, likely hindered AV’s ability to have a consistent understanding of the parameters of a therapeutic relationship which could interfere with other individuals’ attempts to provide therapeutic services to the AV, both now and in the future. Therefore, there was a preponderance of the evidence that the SP failed to maintain professional boundaries and that the SP’s interactions with the AV were detrimental to AV’s ongoing mental health and were a failure to supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV’s physical or mental health.

It was determined that neglect occurred (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).

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

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

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

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

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

The SP was trained on the Reporting of Maltreatment of Minors Act and the facility’s Code of Conduct. 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 was not “recurring” or “serious” maltreatment because the SP’s overall interactions represented a pattern of behavior and therefore a single incident, and the AV did not require the care of a physician.

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

Action Taken by Facility:

The facility completed an internal review and found that their policies and procedures were adequate but not followed. Staff were retrained on Maltreatment of Minors Act and when to report inappropriate staff conduct. The SP no longer worked at the facility.

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

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

Certification:

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

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

doc_type: Maltreatment Finding


state: MN

facility_name: Newport Academy

raw_content:
March 15, 2024

Annie Gendaszek, Authorized Agent

Newport Academy

3990 Hillsboro Pike STE 330

Nashville, TN 37215

License Number: 1108472

Report Number: 202303495

CORRECTION ORDER

Dear Annie Gendaszek:

A licensing investigation of Newport Academy, located at 1726 7th Ave S, Saint Cloud, MN 56301, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, chemical dependency services under Minnesota Rules, part 2960.0430 through 2960.0490, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, and restrictive techniques standards under Minnesota Rules, part 2960.0710. As a result of this licensing investigation a Correction Order is being issued.

A.   Reason for Correction Order

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

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

1. Citation: Minnesota Rules, parts 2960.0050, subparts 1, item F and 2, and 2960.0080, subpart 11, items A and B.

Violation: The license holder’s operational policies and procedures did not describe how the license holder will provide a resident with timely access to medical services to ensure a resident’s basic right to adequate medical care is protected. The Health & Hygiene policy did not identify when medical services would be provided.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure operational polices and procedures are developed to ensure the basic rights of residents are protected. Within 30 days receipt of this order, submit a policy and procedure that describes how the license holder will ensure residents are provided timely access to adequate medical care.

2. Citation: Minnesota Statutes, section 245A.04, subdivision 14 and Minnesota Rules, part 2960.0080, subpart 11, item E.

Violation: The license holder failed to monitor the implementation of procedures identified in the license holder’s Medication Management policy for recording the administration of medications to residents. The policy indicated that a Medication Administration Record (MAR) will document all prescription and non-prescription medications administered to residents. An incident report and nursing shift note dated December 7, 2022, documented that a resident (R1) was administered Tylenol in error, however, it was not recorded as administered on the resident’s medication administration record.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the monitoring of the implementation of policies and procedures meet all applicable requirements.

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

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

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

2. By mail to:

Commissioner, Department of Human Services

ATTN: Tina Christensen

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

B.   Right to Request Reconsideration

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

Commissioner, Department of Human Services

ATTN: Legal Unit

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Sincerely,

Tina Christensen, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

651-431-6610

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


report_date: August 5, 2022

raw_content:
August 5, 2022

Annie Gendaszek, Authorized Agent

Newport Academy

3990 Hillsboro Pike STE 330

Nashville, TN 37215

License Number: 1108472

Report Number: 202203882

CORRECTION ORDER

Dear Annie Gendaszek:

A licensing investigation of Newport Academy, located at 1726 7th Ave S, Saint Cloud, MN 56301, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, and restrictive techniques standards under Minnesota Rules, part 2960.0710. As a result of this licensing investigation a Correction Order is being issued.

A. Reason for Correction Order

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

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

1. Citation: Minnesota Rules, part 2960.0190, subparts 1, item B and 2.

Violation: The license holder failed to follow discharge and treatment plan compliance requirements in the following ways:

a. The file did not contain documentation to demonstrate that the legal guardian was consulted to provide input and develop the transition services plan;

b. The transition plan did not include the following:

1. Leisure arrangements;

2. Vocational rehabilitation or training services;

3. Recommend ways to meet the residents needs and identify resources that are available in the community to address the residents continuing needs after release from the facility; and

4. Consider the environment into which the resident will return, and recommend how the resident may deal with issues and potential challenges within that environment.

c. Discharge documentation did not include the extent to which the residents stay in the facility met the goals and objectives of the resident’s treatment plans including which services, including education, were provided directly or indirectly to the resident and who provided the services and which services were recommended in the resident’s treatment plan but were not provided to the resident.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure discharge and treatment plan compliance requirements are followed and meet all applicable requirements.

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

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

1. By secure email to: heather.prior@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Heather Prior

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

C.   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 me as soon as possible.

Sincerely,

Heather Prior, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

651-431-2694

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


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June 10, 2022

Annie Gendaszek, Authorized Agent

Newport Academy

3990 Hillsboro Pike STE 330

Nashville, TN 37215

License Number: 1108472

CORRECTION ORDER

Dear Annie Gendaszek:

On April 28 and 29, 2022, a licensing review of Newport Academy, located at 1726 7th Ave S, Saint Cloud, MN 56301, was conducted to determine compliance with state and federal laws and rules governing the provision of children’s residential facilities under Minnesota Rules, part 2960.0010 through 2960.0120, children's group residential facilities under Minnesota Rules, part 2960.0130 through 2960.0220, residential mental health treatment under Minnesota Rules, part 2960.0580 through 2960.0690, and restrictive techniques standards under Minnesota Rules, part 2960.0710. As a result of this licensing review a Correction Order is being issued.

A. Reason for Correction Order

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

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

Practices

1. Citation: Minnesota Rules, part 2960.0080, subpart 18, items A and B.

Violation: The license holder failed to meet grievance requirements in the following ways:

a. Grievances dated January 28, 2022 and February 21, 2022 were not responded to within five days of the resident filing the grievance; and

b. The license holder did not document the grievance investigation findings and resulting actions taken for grievances filed on the following dates:

1. March 4, 2022; and

2. March 19, 2022.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure grievance procedures are followed and meet all applicable requirements. Within 30 days receipt of this order, submit two grievances and grievance findings to demonstrate compliance.

2. Citation: Minnesota Rules, part 2960.0140, subpart 1, item A.

Violation: The satisfaction surveys did not include the following required components:

a. The accuracy, usefulness, and appropriateness of the screenings and assessment of the resident’s physical and emotional wellbeing;

b. Support of obtaining needed medical and dental health; and

c. Support of community reintegration, if appropriate.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure satisfaction surveys include all required components and meet all applicable requirements. Within 30 days receipt of this order, submit a revised satisfaction survey form to demonstrate compliance.

Personnel Files

3. Citation: Minnesota Rules, part 2960.0150, subpart 2.

Violation: Two of three personnel files reviewed for requirements governing professional licensure (personnel files numbered 3 and 6) did not meet requirements. The license holder failed to ensure the professional licensure stored in the personnel file was current.

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

4. Citation: Minnesota Statutes, section 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0100, subpart 3, item A, 2960.0150, subpart 4, item C, 2960.0650, subparts 1, item G, 2, items C and G.

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

a. Orientation was not provided to the following:

1. The psychosocial development of boys and girls (personnel files numbered 1, 2 and 9);

2. Sexual orientation issues (personnel files numbered 1, 2 and 9); and

3. Physical, mental, sensory, and health-related disabilities, bias, and discrimination (personnel files numbered 1 and 2).

b. Orientation to the following was not completed before unsupervised contact with residents:

1. Emergency procedures (personnel files numbered 1, 2 and 5 through 8);

2. Cultural diversity and gender sensitivity, culturally specific services, and information about discrimination and racial bias issues (personnel files numbered 5 and 9); and

3. General and special needs, including disability needs of residents and families served (personnel files numbered 5, 6 and 9).

c. The program abuse prevention plan was not reviewed within 72 hours of first providing direct contact services to a vulnerable adult (personnel files numbered 1 through 9);

d. Orientation to problems and needs of residents with severe emotional disturbance and their families was not completed before assuming sole responsibility for the care of residents (personnel files numbered 1, 2, 6, 8 and 9);

e. Facility staff who do not provide program services did not receive orientation to the following:

1. Emergency procedures (personnel file numbered 5); and

2. Problems and needs of residents with severe emotional disturbance and their families (personnel files numbered 4 and 5).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days receipt of this order, submit documentation that the staff identified above received training in paragraphs (a) and (e).

5. Citation: Minnesota Rules, part 2960.0100, subpart 5.

Violation: Nine of nine personnel files reviewed for requirements governing the documentation of training (personnel files numbered 1 through 9) did not meet requirements. Training documentation did not include the number of hours of orientation completed and the name of the entity that provided the training.

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

Resident Files

6.  Citation: Minnesota Rules, part 2960.0160, subpart 2, item C.

Violation: Three of three resident files reviewed for requirements governing admission criteria (resident files numbered 1 through 3) did not meet requirements. The file did not include documentation to demonstrate the license holder determined whether the program is able to meet the needs of the resident’s cultural, emotional, educational, mental health and physical needs.

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

7.  Citation: Minnesota Rules, parts 2960.0070, subpart 5, items A and D.

Violation: Three of three resident files reviewed for admissions procedures and screenings did not meet requirements in the following ways (resident files numbered 1 through 3):

a. The file did not contain documentation to demonstrate that the license holder notified the residents parent, guardian, or custodian within a reasonable time frame after admission that information on the residents basic rights was available; and

b. The health screening did not include the resident’s history of abuse and vulnerability to abuse and the clinic’s name, address and telephone number.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure resident admission procedures and screenings meet all applicable requirements. Within 30 days receipt of this order, submit health screenings for two residents to demonstrate compliance.

8.  Citation: Minnesota Rules, part 2960.0620, subpart 1, item A.

Violation: Three of three resident files reviewed for requirements governing the individual treatment plan (resident files numbered 1 through 3) did not meet requirements. The treatment plan did not include the use of psychotropic medications.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the individual treatment plan meets all applicable requirements. Within 30 days receipt of this order, submit treatment plans for two residents prescribed psychotropic medications to demonstrate compliance.

9.  Citation: Minnesota Rules, part 2960.0620, subparts 2, 6, item A and 7.

Violation: Three of three resident files reviewed for requirements governing psychotropic medication monitoring and the informed consent did not meet requirements in the following ways:

a. The file did not contain documentation to demonstrate that the license holder conducted and documented a psychotropic medication review at least monthly for the first six months (resident file numbered 1);

b. The license holder did not obtain informed consent prior to the administration of a psychotropic medication for the following:

1. Intuniv March 11, 2021; Buspar and Trazodone March 31, 2021 (resident file numbered 1); and

2. Lithium and Zyprexa March 24, 2021; Buspar March 31, 2021 (resident file numbered 2).

c. Written informed consent information did not include the following:

1. Diagnosis (resident files numbered 1 through 3);

2. Methods used to determine the expected benefits (resident files numbered 1 through 3);

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

4. Specific information about the psychotropic medication to be used, including the generic and commonly known brand name, the route of administration, the estimated duration of therapy, and the proposed dose with the possible dosage range or maximum dose (resident file numbered 2);

5. More frequent and less frequent or rare but serious risks and side effects of the psychotropic medication, including how the risks and possible side effects must be managed (resident file numbered 2);

6. Explanation that consent may be refused or withdrawn at any time and that the consent is time-limited and automatically expires in one year (resident file numbered 2); and

7. The names, addresses and telephone numbers of appropriate professionals to contact if questions or concerns arise (resident file numbered 2).

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure psychotropic medication monitoring and the informed consent meet all applicable requirements. Within 30 days receipt of this order, submit informed consents and psychotropic medication reviews for two residents to demonstrate compliance.

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

Violation: One resident file was reviewed for requirements governing the transition services plan and discharge documentation (resident file numbered 2) and did not meet requirements in the following ways:

a. The plan did not recommend how the resident may deal with issues and potential challenges within the environment the resident will return; and

b. The discharge plan did not identify the services, including education, that were recommended in the resident’s treatment plan but were not provided to the resident.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure the transition services plan and discharge documentation meets all applicable requirements.

B. Recommendation

The following recommendation is not a requirement of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas.

· During the licensing review, it was determined that personnel training records were not organized in a retrievable manner. DHS licensing recommends that the license holder develop a plan to ensure training records are stored in an organized manner and are retrievable moving forward.

Failure to follow this recommendation will not result in a fine or action against your license at this time. However, should failure to follow this recommendation result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license.

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

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

1. By secure email to: heather.prior@state.mn.us; or

2. By mail to:

Commissioner, Department of Human Services

ATTN: Heather Prior

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

C.   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 me as soon as possible.

Sincerely,

Heather Prior, MH/SUD/CRF Senior Licensor

Licensing Division

Office of Inspector General

651-431-2694

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


facility_name: Nexus East Bethel Family Healing

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Notice: This Amended Order of Temporary Immediate Suspension supersedes the original Order of Temporary Immediate Suspension dated May 15, 2026. This document is amended to change the date the temporary immediate suspension goes into effect.  In order to provide for the continuity of care of service recipients, the immediate suspension will go into effect on Saturday, June 6, 2026, at 12:01 AM.  After this time, you are prohibited from providing children’s psychiatric residential treatment services at this facility.  The timeline to appeal the Temporary Immediate Suspension is five (5) days from when you received the original Order of Temporary Immediate Suspension.  See the “Your Right to Appeal” section below.  The original Order of Temporary Immediate Suspension dated May 15, 2026, must be destroyed.

Date issued: May 15, 2026

Date reissued: May 26, 2026

Electronic Delivery

Michelle Murray, Authorized Agent

Nexus Family Healing

505 HIGHWAY 169 N STE 500

Plymouth, MN 55441

License Number: 1119782 (PRTF)

AMENDED ORDER OF TEMPORARY IMMEDIATE SUSPENSION

Dear Michelle Murray:

The Department of Human Services (DHS) is immediately suspending your license to provide children’s psychiatric residential treatment services at Nexus East Bethel Family Healing, 900 189th Ave NE, East Bethel, MN, 55011. This immediate suspension is based on a determination that children served by your program are at an imminent risk of harm. Details of our findings are provided below. Our next steps and your options are also detailed.

The immediate suspension goes into effect on Saturday, June 6, 2026, at 12:01 a.m., or when all service recipients have been transitioned to a new provider, whichever comes first. After this time, you are prohibited from providing children’s psychiatric residential treatment services.

REASON FOR TEMPORARY IMMEDIATE SUSPENSION

There is an imminent risk of harm to persons served.

On May 13, 2026, DHS determined that:

· Residents basic rights were not protected;

· Allegations of suspected maltreatment were not reported as required by mandated reporters;

· The plan of care was not updated in response to changing conditions;

· Medications were not administered safely and accurately;

· There was not enough appropriately trained staff to ensure the resident’s treatment needs could be met;

· Treatment services did not include adequate supervision to support resident safety;

· The response to behavior that presented imminent risk of harm was ineffective;

· The facility was not kept in good repair; and

· Implementation of policies and procedures related to safety and supervision was not monitored.

Because this report is currently under investigation, no additional information can be released in this order.

Based on these findings, DHS cannot ensure the health and safety of the children served by your program at this time. DHS has determined there is an imminent risk of harm to the health, safety, and rights of children in your care. Therefore, DHS is suspending your license to provide children’s psychiatric residential treatment services.

Legal Authority: Minnesota Statutes, section 245A.07, subdivision 2(a)(1).

YOUR RIGHT TO APPEAL

On May 19, 2026, DHS received your timely request for a contested case hearing, and the case will be scheduled for a hearing in front of an Administrative Law Judge at the Court of Administrative Hearings. There is no need to submit another appeal request.

Legal representation at the contested case hearing:

You do not need a lawyer to appeal. However, a lawyer can help you with your appeal. The state or county will not get you a lawyer and will not pay for a lawyer. If you cannot afford a lawyer, you may be able to get free legal advice or help with your appeal. To find out if free help is available, contact: Volunteer Lawyers Network at 612-752-6677; Central Minnesota Legal Services at 612-332-8151; Southern Minnesota Legal Services at 651-222-4731; or go to www.lawhelpmn.org to find a local legal services program that may be able to help you.

You can also find information on contested cases from the Office of Administrative Hearings website at https://mn.gov/oah/self-help. Click on Administrative Law Overview, then click on Administrative Law Contested Case Hearing Guide for a list of frequently asked questions.

Legal authority in this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 2(a), which describes under which conditions DHS may immediately suspend a license.

· The timeline to appeal a temporary immediate suspension order is provided in Minnesota Statutes, section 245A.07, subdivision 2(b).

· Because reports of alleged maltreatment and licensing violations remain under investigation, additional information is considered “confidential data” under Minnesota Statutes, section 13.46, subdivision 3.

· Under Minnesota Statutes, section 245A.07, subdivision 2b, the effective date of the TIS may be delayed for up to 30 calendar days to provide for the continuity of care of service recipients.

· License holders have a right to appeal licensing actions and request a contested case hearing, under Minnesota Statutes, chapter 14 and Minnesota Rules, parts 1400.8505 to 1400.8612.

Questions

If you have any further questions regarding this matter, you may contact Katie Leuer, Unit Manager, at 651-431-6259.

Sincerely,

Jason Flint, Interim Director

Licensing Division

Office of Inspector General

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

doc_type: Notice


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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: 202601793

Date Issued: April 14, 2026

Name and Address of Facility Investigated:

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

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

Maltreatment not determined as to physical abuse of the alleged victim by the staff person.

License Number and Program Type:

1119782-PRTF (Psychiatric Residential Treatment Facility)

Investigator(s):

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

651-431-6616

Suspected Maltreatment Reported:

It was reported that a staff person (SP) shoved an alleged victim (AV) and they “locked arms.” The AV tried to break away/back away from the SP, but the SP grabbed the AV’s shirt and hair, then grabbed both the AVs’ arms and pulled the AV toward the SP. A staff person (P1) intervened, and after the incident, the AV had red marks on both arms, a scratch on the right forearm and on the lower back, and pain where his/her hair was pulled, but no injuries were observed to his/her scalp.

Date of Incident(s): February 19, 2026

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 19, 2026; from documentation at the facility; and through interviews conducted with P1, the SP, the AV’s guardian (G), and the AV.

The facility provided individualized trauma informed psychiatric residential treatment services to youth from 10-19 years of age who had significant mental and behavioral health issues. The facility had a video recording system that recorded videos in the facility’s common areas, but the system did not record audio.

Facility documentation showed that the AV had a history of engaging in self-harm and attempting to leave or leaving facilities without supervision. The AV’s diagnoses included disruptive mood dysregulation disorder and post-traumatic stress disorder. The AV might feel overstimulated when others raised their voices, and s/he might raise his/her voice in response or might become physically aggressive when others were aggressive or when there was physical conflict. The AV wanted to learn to manage his/her feelings and improve his/her communication skills. The AV liked spending time with friends.

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

· The AV said that on the date of the incident, s/he and another youth (Y) attempted to leave the facility without supervision from a staff person. The Y exited the facility, and staff persons followed him/her, but the AV did not leave the facility and sat on a bench in a facility common area. A health care professional (HCP) and the SP were near the AV but after a few minutes, the HCP left the area to prepare medications for the AV and other youth. The VA was upset, and the SP remained with him/her.

· According to the AV, the SP told the AV that s/he did not know why the AV was upset because the AV had not been hit or kicked and told the AV that s/he was a “stupid little brat.” The SP continued, saying that s/he “could not take this fucking shit with [the AV] anymore.” The AV replied, “Then don’t,” and the SP approached the AV, said that the AV should not be crying, and told the AV that s/he was better than this, needed to do better, and that this was stupid. The SP kept moving toward the AV, so the AV extended his/her hand to create space between him/herself and the SP, but the SP did not stop, and the AV felt uncomfortable. The AV stood and backed away from the SP, but the SP “came after” the AV, grabbed his/her arms, and “whipped” the AV around, then grabbed the AV’s hair on the back of his/her head, and pulled it. The AV screamed at the SP to “get off” of him/her, but the SP did not let go of the AV until P1, who had been in the staff person office, approached them and instructed the SP to release the AV. The SP released the AV, and the AV ran down the hall to another part of the facility.

· The AV said that after the incident, s/he had red marks on his/her left side and back, bruises on his/her arms, and had a bump on his/her head for two weeks where the SP pulled his/her hair. On the date of the site visit, the AV showed this investigator a mark on his/her mid back that s/he said was from an injury s/he sustained during the incident. The mark appeared to be a recently healed scratch.

· The video recording from the facility showed that at 7:24:53 p.m. on February 19, 2026, the AV was seated in a common area of the facility while the SP stood about eight feet from the AV. At 7:24:56 p.m., the AV stood and quickly moved toward the SP, then pushed the SP near his/her chest. The SP pushed the AV with his/her right hand, the AV moved backward, and the SP moved toward the AV, then grasped the AV’s arms near the outer/upper arms and the AV grabbed the SP’s arms. The SP and AV held onto each other’s arms/hands and moved in a circle, struggling with each other. At 7:25:06 p.m., the SP grabbed the hair at the back of the AV’s head with his/her left hand and pulled it. The AV bent forward at the waist, and the SP placed his/her right hand near the AV’s head, then released the AV’s hair and grabbed the AV’s arms again with both hands. The AV attempted to pull away or back away from the SP and P1 began walking toward the SP and AV. At 7:25:16 p.m., the SP released the AV, who held the back of his/her head with his/her hands and walked away from the common area. The SP and P1 walked toward the AV, but the SP stopped in the common area and P1 continued following the AV, who was still holding the back of his/her head with his/her left hand. At 7:25:31 p.m., the AV moved out of the camera’s view, followed by P1. The SP remained in the common area for a few additional seconds, then left the common area in a different direction.

· The SP said on the date of the incident, his/her scheduled shift was in another unit at the facility, not in the unit in which the AV resided, and s/he had not met the AV prior to the incident. The SP was tired because tension was high at the facility all day and the SP wanted to take a break, but s/he was unable to because there were not enough staff persons to supervise the youth at the facility. Youth were kicking facility doors and planning to leave the facility without supervision to meet in a wooded area near the facility. In addition, a youth who resided in another unit hit the SP in the face prior to the incident with the AV. Multiple youth were in crisis at the facility, and the SP and several staff persons were assisting with the situation. The SP was with the AV while other staff persons were outside attempting to redirect the Y back into the facility.

· When the SP supervised the AV, the AV was upset and told the SP that the common area was too loud. The SP wanted to redirect the AV back to his/her unit, so s/he attempted to dysregulate the AV as s/he had been trained to do by talking loudly to the AV to make the common area an unpleasant environment for the AV to encourage the AV to return to the unit in which s/he resided. The AV then lunged at the SP, who went into “self-defense” mode and attempted to bear hug the AV to hold his/her arms to his/her side. The SP was unable to hold the AV and there was no one the SP could call for support or back up. The SP continued to try to hold the AV’s arms to his/her side but could not grasp the AV and one of the SP’s rings became tangled in the AV’s hair. The SP was initially unable to untangle the ring from the AV’s hair, and s/he was afraid that the AV would pin him/her against a wall or get him/her to the ground and hurt him/her. The SP’s ring loosened from the AV’s hair, and the SP separated from the AV, then P1 approached the AV and SP after exiting his/her office. The SP removed him/herself from the area and had no additional contact with the youths at the facility.

· The SP felt that s/he should not have been asked to supervise youth in another unit, and that s/he received conflicting training and feedback. A staff person whose identity the SP could not recall told him/her that the SP “froze” during crises and the SP did not want to freeze with the AV. In hindsight, the SP thought s/he should have listened to the AV’s concerns, and stepped back then blocked the AV’s aggressive actions, but the incident happened so fast that the SP was unsure whether s/he had time to deflect the AV. When staff persons used radios to communicate with each other or wore earpieces, the youth at the facility actively attempted to take the radios from staff persons and “rip” the earpieces from their ears. The SP felt that staff persons had no authority at the facility.

· P1, a supervisory staff person, said that s/he did not witness the entire incident but was in an office in a virtual meeting when it began and heard raised voices coming from the hall. P1 exited the office and walked toward the common area where s/he saw the SP holding the AV by his/her forearms which did not look consistent with restraints or procedures that staff persons were trained to use at the facility. P1 instructed the SP to release the AV, and s/he did. The AV cried and backed away from the SP, then ran down a hall away from the common area. P1 followed the AV and asked him/her what was wrong, and the AV replied that the SP pulled his/her hair, yelled at him/her, and grabbed at him/her.

· P1 asked the HCP to assess the AV, viewed the video recording of the incident, and then asked the SP what happened. The SP told him/her that s/he had to “get big” and put the AV in his/her “place.” P1 discussed the incident with a supervisory/administrative staff person, and it was decided that the SP should leave the facility immediately and the rest of the shift was uneventful. P1 said that staff persons were instructed that their responses to the youths’ requests might dysregulate the youths, but staff persons were not trained to intentionally dysregulate the youths. Staff persons should not be afraid to tell youths no if youths asked to participate in an activity that was not in the youths’ best interest or if the activity was not consistent with the facility’s policies and procedures. If the SP had called for assistance using a radio, P1 would not have heard the call, because his/her radio was turned down while s/he was in the meeting, but s/he heard yelling/raised voices and left the office immediately to intervene.

· This investigator attempted to contact the SP again to ask whether the SP called the AV a little brat, said that s/he could not “take this fucking shit anymore,” or told the AV that s/he was better than this, needed to do better, that this was stupid, or said that s/he had to “get big” to put the AV in his/her place. However, the SP did not respond to additional attempts to contact him/her.

· A Progress Note written by the HCP at 8:20 p.m., on February 19, 2026, showed that the HCP observed that there was redness on both of the AV’s biceps, a red scratch on the top of the AV’s right forearm, and some redness on his/her left forearm. There were no visible injuries to the AV’s scalp, the scalp was not red, and there was no missing hair. The AV was given a cold pack to apply to painful areas according to the Internal Review.

· Photos of the AV’s injuries provided by the facility showed that the AV had a scratch approximately .25 inch long on his/her upper left back with broken skin that was healing over with redness around the scab, faint redness on the AV’s right forearm, and on his/her right and left biceps.

· The facility’s staffing schedule for the date of the incident showed that eight staff persons and the HCP were at the facility and there were twenty-two youths who resided at the facility. The staffing ratio at the facility was one staff person for three youths. The facility was within staffing ratio when the incident occurred.

· The G was aware of the concerns investigated in this report and was concerned that the AV was able to leave the facility without staff person supervision on several occasions. The AV had a history of providing inaccurate information.

The facility’s Restraint Procedures Policy showed that staff persons were permitted to use physical restraints to protect a youth or others from imminent risk of harm. The SP’s actions in the incident did not fit the description of restraints that the facility utilized.

The facility’s personnel and training records showed that staff persons who provided information for this report were trained on the Maltreatment of Minors Act and the facility’s policies and procedures prior to the incident. The SP was trained on the facility’s policies and procedures between January 5 and January 26, 2026, and refresher courses on February 16, 2026.

Conclusion:

A. Maltreatment:

Information was consistent that on February 19, 2026, there was a physical interaction between the AV and the SP. The AV said that the SP called him/her a stupid little brat, said that s/he could not take “fucking shit” with the AV anymore, grabbed the AV’s arms, whipped the AV around, and pulled the AV’s hair. After the incident, the AV had red marks on his/her side and back, bruises on his/her arms, a bump on his/her head, and a mark on his/her back that might have been from a recently healed scratch.

The SP said that many youth at the facility were in crisis on February 19, 2026, s/he had not met the AV prior to the incident, and the SP had been hit by another youth earlier that day. While supervising the AV in the common area, the SP attempted to redirect the AV to the unit in which s/he resided by talking loudly to create an unpleasant environment for the AV. The AV lunged toward the SP and the SP attempted to hold the AV’s arms to his/her side, but a struggle followed, the SP’s ring became tangled in the AV’s hair, and the SP was afraid that the AV would pin him/her against a wall or get him/her to the ground and hurt him/her. The SP untangled the ring from the AV’s hair and released it but continued to hold the AV’s arms. P1 then approached the SP and AV.

P1 said that s/he became aware of the incident when s/he was attending a virtual meeting in the office but heard raised voices in the common area. P1 exited the office and observed the SP holding the AV’s forearms in a way that was inconsistent with facility policies and procedures, so s/he instructed the SP to release the AV, and s/he did. According to P1, the AV told him/her that the SP pulled the AV’s hair, and yelled and grabbed at the AV. The SP told P1 that s/he had to “get big” to put the AV in his/her “place.”

The video recording showed that the AV moved toward the SP and pushed him/her. The SP pushed at the AV, the AV moved backward, and the SP moved toward him/her then the AV and the SP grabbed each other’s arms, moved in a circle, and struggled with each other. The SP grabbed the AV’s hair and the AV bent forward at the waist, and the SP placed his/her right hand near the AV’s head then released the AV’s hair and grabbed the AV’s arms again with both hands. The struggle continued, but when P1 exited the office and walked toward the SP and AV, the SP released the AV, and the AV walked away from the common area followed by P1. The SP then left the common area in a different direction. The incident lasted about less than one minute.

After the incident, an HCP assessed the AV and documented that there was redness on both of the AV’s biceps, a red scratch on the top of the AV’s right forearm, and some redness on his/her left forearm. There were no visible injuries to the AV’s scalp, the scalp was not red, and no missing hair was noted.

P1 and the facility’s Restraint Procedures and Policy showed that the SP’s actions were not consistent with permitted restraints at the facility.

This investigator attempted to contact the SP again to ask whether the SP called the AV a brat, said that s/he could not “take this fucking shit anymore,” or said that s/he had to “get big” to put the AV in his/her place, but the SP did not respond.

Regarding neglect:

Although it was unknown whether the SP called the AV a brat or used profanity with the AV, given that P1 said that the SP told him/her that s/he had to “get big” to put the AV in his/her place, that the video showed the SP push the AV and hold his/her arms, that the SP did not physically disengage with the AV and walk away, and that the SP’s actions during the incident were non-therapeutic and not consistent with facility policies and procedures, there was a preponderance of the evidence that there was a failure to supply the AV with care required for his/her physical or mental health when reasonably able to do so.

It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with

necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so; or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Regarding abuse:

Although the AV had redness on his/her arms and a scratch on his/her back after the incident, given that the AV had aggressive behavior during the incident, that no information showed that the AV sustained the redness and scratch by any means other than accidental, and that the SP said that s/he was trying to hold the AV’s arms to his/her side, it was determined that the SP’s actions, while nontherapeutic, did not meet the definition of physical abuse.

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

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

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

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

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

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

The SP was responsible for supervising the AV at the time of the incident and was trained on the facility’s policies and procedures prior to the incident. The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not sustain injuries during the incident that reasonably required the care of a physician.

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

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but not followed. The SP was not injured during the incident and was no longer employed at the facility when this report was written.

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/


report_date: December 29, 2025

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

Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.”

Report Number: 202410719

Date Issued: December 29, 2025

Name and Address of Facility Investigated:

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

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

License Number and Program Type:

1119782-CRF (Children’s Residential Facility)

Investigator(s):

Gessner Rivas
Minnesota Department of Human Services
Office of Inspector General, Licensing Division
PO Box 64242
Saint Paul, Minnesota 55164-0242
651-431-3970

Gessner.rivas@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) provided an alleged victim (AV) personal snacks and allowed the AV to watch television past the time allowed, provided the AV with a nicotine vape pen, had inappropriate conversations with the AV, and showed the AV sex videos of the SP.

Date of Incident(s): December 11-12, 2024

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on December 20, 2024; from documentation at the facility; and through three interviews conducted with two supervisory staff persons (P1 and P2), and the alleged victim (AV). Attempts to contact and interview the AV’s guardian were unsuccessful.

The SP did not respond to this investigator’ attempts to request an interview with the SP.

The facility provided individualized, trauma informed psychiatric residential treatment (PRTF) services to youth ages 10-19 who had significant mental and behavioral health concerns. The AV was diagnosed with anxious personality disorder, borderline personality disorder, and ADHD. The AV’s Individualized Crisis Management Plan noted that the AV had a history of sexual abuse. The AV enjoyed visits with family, activities like bowling, swimming, and listening to music.

The AV stated that the SP usually worked overnight and would let the AV watch a crime show on television and have personal snacks such as chips and candy bars. Such snacks were only allowed during a resident’s free time. The SP showed the AV two videos depicting the SP’s sexual encounters; in one video the SP was being tied up by her/his partner and the second video was of the SP having sex. The videos made the AV uncomfortable to watch and the AV wanted to sleep in more and had a loss of appetite. The AV stated that the SP told her/him, “I’m just showing you to get you to feel comfortable around me.” The SP talked to the AV about sexual “kinks” and asked the AV if s/he had any; the AV did not respond. The AV could not recall when the SP showed the AV the sex videos, but stated it was same week the AV talked to P1 and P2. The AV also stated that the SP provided her/him with a peach mango flavored nicotine vape pen that the AV used. The SP told the AV that if s/he did not come back for it, to “flush it down” the toilet.

P1 and P2 provided the following information:

· On December 13, 2024, P1 was notified that the AV told a staff person the SP had provided the AV with a nicotine vape pen, and that on the evening of December 12, 2024, the SP allowed the AV to watch a crime show on television while sharing a meat, cracker, and cheese tray with the AV.

· P1 approached the AV and asked if s/he would be willing to talk to P1 and P2. During that meeting, the AV disclosed that the SP had provided her/him with a vape the night before, threatened the AV not to tell anyone, and told the AV to flush the vape when finished, which the AV did. The AV stated that the SP had planned to bring the AV and another resident a “vape” on December 13, 2024. The AV also disclosed that the SP had discussed sexual “kinks” with the AV and shared a sex video of the SP and her/his partner. P1 and P2 stated that sharing such videos with the AV, triggered the AV’s history with sexual abuse. P1 did not know if anyone witnessed the SP share the videos with the AV. According to P1, the AV stated that the SP showed the AV the videos around two weeks prior to December 13, 2024.

· With respect to allowing the AV to watch a crime show, the SP was not following programing expectations, was not appropriate for the AV due to the violent content, and the AV should have been in bed. Likewise with snacks, residents were allowed to have personal snacks during their free time. If residents wanted snacks at any other time, residents were allowed to have snacks provided by the facility such as fruit but not personal snacks.

· At the time of the alleged incidents, the AV was housed in one unit and the SP was assigned to work in a different unit at the facility.

The facility spoke with the SP about the allegations regarding giving the AV a nicotine vape and talking about sex with the AV. The SP denied talking to any resident about vaping but mentioned that a different resident had asked the SP to bring her/him a vape which the SP declined. The SP denied having any conversation about sex with any resident but mentioned that a resident asked to see a picture of her/his partner but only showed the resident a headshot of the SP’s partner.

The facility conducted an Internal Review which consisted of reviewing camera footage from the evening of December 11-12, 2024. Camera footage showed that the SP and the AV were watching tv around 11:20 p.m. and that the AV appeared to have fallen asleep on the floor. The review noted that there was no evidence of the SP passing a vape to the AV or allowing the AV to view the SP’s phone. The review went on to state that the SP did not follow protocol regarding watching television after “lights out” and that the SP would receive retraining related to bedtime expectations.

The facility’s Alcohol and Drug Abuse/Testing policy prohibited staff persons from possessing controlled substances (defined as substances controlled by federal or state statutes) on the premises of the facility. The facility’s Employee Handbook also noted that the premises was a non-smoking (including e-cigarettes) and tobacco free work environment.

Minnesota Statute, section 609.685, stated in part that persons under the age of 21 cannot be sold, given, or otherwise furnished tobacco, tobacco-related devices, or electronic delivery devices.

Facility records showed that the SP was trained on the facility’s policies and on the Reporting of Maltreatment of Minors Act.

Conclusion:

A. Maltreatment:

The AV provided consistent information that the SP provided the AV with a nicotine vape pen which the AV used and flushed down the toilet when s/he was done with it. In addition, the SP showed the AV personal videos of the SP engaged in sexual acts with a partner. The AV was interviewed by P1, P2, and this investigator about the allegations of the SP’s actions and provided consistent information. The SP denied the allegations to the facility and did not respond to requests for an interview with this investigator.

The SP’s conduct of giving the AV a vape, having an inappropriate discussion with the AV, and showing the AV sex videos was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although the SP denied the allegations, given that the AV provided consistent information about the alleged maltreatment, and that SP had reason to minimize his/her actions for fear of repercussions, it was more likely that the incidents occurred as described by the AV. Therefore, there was a preponderance of the evidence that the SP provided the AV with a vape, allowed the AV to watch a crime show, had an inappropriate discussion with the AV, and showed the AV personal sexual videos which was a failure to supply the AV with necessary care and a failure to protect the AV.

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

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

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

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

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

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

The SP was trained on the facility’s relevant policies and the Reporting of Maltreatment of Minors Act prior to the incident. The SP was responsible for maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring because the SP’s actions were considered a single pattern of behavior or serious because it did not meet the statutory definition.

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 found that policies were adequate but not followed with respect to programming expectation and the SP would be retrained on bedtime expectations.

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/