report_date: December 11, 2025

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

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

Report Number: 202504560

Date Issued: December 11, 2025

Name and Address of Facility Investigated:

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

Disposition: This error in the provision of the therapeutic conduct to a vulnerable adult by a staff person was not maltreatment.

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

651-431-6616

carla.harvieux@state.mn.us

Suspected Maltreatment Reported:

It was reported that a vulnerable adult (VA) was unsupervised in a facility bathroom for about forty minutes. When staff persons located the VA, s/he had tied strips of cloth around his/her neck and was unconscious. The VA’s face was “blue.”

Date of Incident(s): May 19, 2025

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on June 26, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (SP1, SP2, P1, P2, P3, and P4) and the VA. The VA was not subject to guardianship.

The facility provided services to individuals aged 12 to 19 with significant mental and behavioral health issues in a program to support families throughout the treatment process. The facility had a video recording system that recorded common areas of the facility, but the video recordings did not have sound. On campus, individuals received education services, therapies personalized to their needs, and recreational opportunities. The VA was 18 years old when the incident occurred.

Facility documentation showed that the VA was diagnosed with generalized anxiety disorder and post-traumatic stress disorder and might become upset when others made comments about his/her appearance or brought up past events being his/her fault. The VA found the gender of some staff persons “triggering” and might have flashbacks when they were present. Positive affirmations and encouragement calmed the VA when s/he was upset. Declining to eat or asking to be alone in a room or bathroom was an indication that the VA might be agitated. Staff persons were to check on the VA often when s/he was not in a group of individuals and were to have near constant verbal checks with him/her when s/he was using the bathroom or taking a shower because many of the VA’s prior self-harm incidents occurred in the bathroom. If the VA made sounds that seemed like something might be wrapped around his/her neck or his/her voice sounded muffled or different when s/he was out of staff persons’ sight, they were to immediately check on the VA. If staff persons thought that the VA might engage in self-injurious behavior, they were to use a Columbia Suicide Severity Rating Scale to assess the VA. The VA’s April 29, 2025, Individualized Treatment Plan (ITP) showed that the VA was on five-minute increased checks for suicidal ideation and no information showed that the frequency of checks decreased prior to the incident. The VA enjoyed listening to music and wanted to live unsupervised in an apartment.

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

· Information was consistent from the VA, SP1, SP2, P1, P2, and a facility Incident Report completed after the incident. P1, P2, and P4 were supervisory/administrative staff persons and SP1 was a milieu lead. On

May 19, 2025, the VA was attending an education program at the facility. P1, P2, P4, SP1, and the VA each stated that the VA and SP1 knew each other prior to the VA’s admission to the facility because SP1 previously worked at a facility in which the VA resided. The VA’s team at the facility decided that it would be best for the VA and SP1 to have no contact with each other at the facility because the VA engaged in more self-injurious actions when SP1 was present. SP1 thought that the VA’s attempts to harm him/herself when SP1 was present increased because the VA wanted SP1 to save or rescue him/her. SP1 did not work on units within the facility in which the VA resided.

· Just before 1:15 p.m. on the date of the incident, the VA was in a classroom and asked the teacher (who was not a facility staff person), to use the bathroom, and the teacher used a walkie talkie to ask staff persons to walk with “a student” from the classroom to the bathroom, but no information showed whether the teacher specified that the VA was the student who needed to use the bathroom. SP1 went to the classroom to assist the teacher and then learned that the VA was the student who needed to use the bathroom.

· According to SP1 and a review of video recordings at the facility, SP1 walked with the VA from the classroom to a common area of the facility, where SP2 and P3 sat. The video recording showed that at 1:14:39 p.m., SP1 was in the common area and made a hand gesture in the direction of SP2. SP1 spoke and when s/he did, SP2 slightly nodded his/her head at 1:14:42 p.m. It was unclear what SP1 said or whether s/he transferred the supervision of the VA to SP2, but SP1, SP2, and P3 remained seated in the common area, and the VA walked away from the common area then entered the bathroom. The video recording showed that many staff persons walked by the bathroom while the VA was in the bathroom. At 1:54 p.m., a staff person (P5) walked near the bathroom and then entered it. A few seconds later, multiple staff persons including SP2, P3, and a facility health care professional (HCP) went to the bathroom. The HCP entered the bathroom, left it, and returned quickly with medical equipment. A couple minutes later, the VA and the HCP exited the bathroom. The recording showed that the VA was unsupervised in the bathroom for about 45 minutes.

· SP1 stated that s/he did not know that the VA was the student who needed the bathroom, but as soon as s/he could, s/he handed off the supervision of the VA to SP2. SP1 said that s/he told SP2 that the VA needed to go to the bathroom, and asked SP2 to watch the VA. SP2 nodded, and at that point, SP1 thought that SP2 was responsible for supervising the VA.

· SP2 said that when the VA and SP1 entered the common area, SP2 was writing shift notes on his/her laptop and talking with a new staff person who was working his/her first shift. SP1 made a general statement that a youth was in the bathroom and SP2 felt that SP1’s statement was not a direct clear transfer of the VA’s supervision to SP2. SP2 and P3 talked with the new staff person but did not hear any noises of distress from the bathroom, then SP2 suddenly heard gasping from the bathroom and P5 ran into the bathroom where s/he observed the VA lying on the floor and turning “blue.” SP2 called for assistance, and P5 used scissors to cut strips of cloth that were tied around the VA’s neck. SP2 thought the bathroom was about 20-25 feet from the common area.

· P3 said that on the date of the incident s/he, SP1, and SP2 were in a common area of the facility working on documentation on their laptops. The teacher called for a staff person to take a student to the bathroom but did not use initials of the student. SP1 answered the call, went to the classroom, and returned to the common area with the VA. Staff persons were aware that the VA had reactive attachment disorder which meant that the VA was more likely to harm him/herself after having contact with SP1 and therefore, the VA and SP1 were not to have contact. According to P3, s/he did not fully recall the exchange, but s/he thought that SP1 told SP2 that the VA needed to use the bathroom, and said, “You need to watch” him/her. SP2, who was using his/her laptop, responded by saying, “Uh huh.” SP1 soon left the common area to respond to a crisis in another part of the facility. P3 continued working and SP2 forgot that the VA was in the bathroom and did not realize the VA was unsupervised until they all heard choking sounds coming from the bathroom.

· P4, an administrative staff person, said that when s/he reviewed the video recording of the incident, s/he observed that after SP1 walked with the VA to the common area, SP1 remained in the common area for about two minutes, then left the common area to assist staff persons on another unit in the facility. SP1 returned to the common area about ten minutes later, and remained in the common area with other staff persons until the VA was located in the bathroom at about 1:55 p.m.

· P5 provided information in the facility’s Internal Review which showed that s/he heard sounds when s/he walked by the bathroom and then entered the bathroom to determine the source of the sounds. P5 located the VA in a bathroom stall and used his/her hands and scissors to remove cloth items from the VA’s neck. One of the fanny packs worn by a staff person did not have scissors in it, and there was an extremely short delay before another staff person gave P5 scissors from his/her fanny pack. P5 was facing the VA, and his/her back was to the staff persons, so s/he was unsure which staff persons had scissors and which did not. SP2 called for assistance and the HCP responded then evaluated the VA, but the VA did not require medical care from a physician.

The facility’s Program Abuse Prevention Plan (PAPP) documented in several places that staff persons were to check on all youths at a minimum of every 15 minutes to ensure ongoing safety. Checks might be increased to 5- or 10-minute intervals depending on an individual’s vulnerability and safety needs. Checks were to be reassessed as needed.

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

Relevant Rule/s and Statute/s:

Minnesota Rules, chapter 2960V.06, subpart 2, subitems (8) and (9) stated that each resident shall be prescribed an individualized program, that does the following: ensures all PRTF service staff in regular contact with the resident are aware and understand each resident’s needs, goals and services identified on the plan of care and ensures all PRTF staff engage residents in continuous and intentional interaction designed to meet the resident’s needs regardless of the setting or activity during all waking hours including day, evening, and weekends.

Conclusion:

The facility provided services to individuals aged 12-19 and the VA was 18 years old when the incident occurred. When the VA was agitated, s/he might try to isolate him/herself from others and when the VA was upset, staff persons were to check on the VA often.

If staff persons thought that the VA might have self-injurious behavior or was in the bathroom, they were to have almost constant verbal contact with him/her. If the VA’s voice sounded muffled or different, staff persons were to immediately check on him/her.

Information was consistent that SP1 was not to work with the VA when the incident occurred, and SP1 said s/he transferred supervision of the VA to SP2 as soon as they reached the common area.

SP2 said that when the VA and SP1 entered the common area, SP2 was working on his/her laptop and talking with the new staff person. SP2 thought that SP1 did not clearly transfer the VA’s supervision to him/her.

The video recording showed that SP1 and the VA walked into the common area, and that SP2 gave a slight nod toward SP1 and the VA after SP1 spoke.

P3 did not fully recall the conversation between SP1 and SP2 on the date of the incident, and s/he and SP2 were using their laptops when SP1 and the VA entered the common area. P3 thought that SP1 told SP2 that the VA needed to use the bathroom, and that SP2 needed to “watch” the VA. SP2 responded by saying, “Uh huh,” and SP1 soon left the common area to respond to a crisis in another part of the facility. P3 continued working and thought that SP2 forgot that the VA was in the bathroom. SP2 and P3 did not realize the VA was unsupervised until they heard choking sounds coming from the bathroom. The VA was assessed by the HCP after the incident and did not require medical care.

Minnesota Statutes, section 626.5572, subdivision 17, paragraph (c), clause (4), states, “A vulnerable adult is not neglected for the sole reason that an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care.

SP1 realized that s/he should not supervise the VA and transferred supervision of the VA as soon as possible to SP2, therefore, his/her responsibility was mitigated. No information showed that P3 was responsible for the VA’s supervision during the incident.

The VA was unsupervised in the bathroom for about 45 minutes which was a violation of Minnesota Rules, chapter 2960V.06, subpart 2, subitems (8) and (9), and the facility’s policies and procedures. The VA used the unsupervised time to wrap items around his/her neck, which caused his/her face to discolor. Information was consistent from SP1 and P3 that SP2 was responsible for the VA’s supervision when the incident occurred.

However, it was determined that SP2’s actions were an error in the provision of therapeutic conduct given that SP2 stated that SP1 did not clearly transfer supervision of the VA to SP2 so was considered a miscommunication, that the VA was assessed after the incident and did not require the care of a physician, that the VA returned to his/her previous state, that there were no past incidents between the VA and SP2, and that the facility reported the incident timely and identified what corrective actions needed to be completed, retrained staff persons, and sufficiently documented their actions for review and evaluation.

This error in the provision of therapeutic conduct to the VA by SP2 was not maltreatment.

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

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but were not followed. SP1 and SP2 were retrained on communication skills, teamwork, and the importance of appropriate supervision and were to re-read the facility’s PAPP. SP1 received coaching and corrective action, and the PAPP was revised to show that when a staff person was responsible for supervising a youth, they were responsible for the supervision of the youth until they handed off supervision of the youth to another staff person in person with a verbal statement that responsibility for supervision was being handed off. Change in supervision was not considered complete until the person taking accountability for the youth confirmed their understanding of the transfer.

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

SP2 was not substantiated as a perpetrator of maltreatment of the VA because the Department of Human Services found that the incident for which SP2 was responsible met the criteria to be determined an error. SP2 was notified by the Office of Inspector General that any future incident of possible neglect of a vulnerable adult for which SP2 is responsible might not be considered an error.

On December 11, 2025, the facility was issued a $200 fine failing to ensure the VA was supervised for about 45 minutes which allowed the VA an opportunity to harm him/herself. The Order to Forfeit a Fine is subject to appeal.

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


state: MN

facility_name: Nexus East Bethel Family Healing

raw_content:
December 11, 2025                  CERTIFIED MAIL

Michelle Murray

Nexus East Bethel Family Healing

505 Highway 169 N Suite 500

Plymouth, MN 55441

License Number 1119782 (Psychiatric Residential Treatment Facility)

Report Number 202504560

ORDER TO PAY A FINE

Dear Michelle Murray:

The Department of Human Services (DHS) is ordering you to pay a fine of $200 for one health and safety violation at Nexus East Bethel Family Healing located at 900 189th Ave NE, East Bethel, Minnesota. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

Violation of Health and Safety

Citation: Minnesota Rules, chapter 2960V.06, subpart 2, subitems (8) and (9) stated that each resident shall be prescribed an individualized program, that does the following: ensures all PRTF service staff in regular contact with the resident are aware and understand each resident’s needs, goals and services identified on the plan of care and ensures all PRTF staff engage residents in continuous and intentional interaction designed to meet the resident’s needs regardless of the setting or activity during all waking hours including day, evening, and weekends.

Violation: A client’s (C) Individualized Crisis Management Plan stated that staff persons were to check on the C often when s/he was not in a group of individuals and were to have near constant verbal checks with him/her when s/he was using the bathroom or taking a shower because many of the C’s prior self-harm incidents occurred in the bathroom.

Based on a maltreatment investigation, DHS determined that on May 19, 2025, the C was unsupervised in the bathroom for approximately 45 minutes and during that time, no staff person checked on the C, which allowed the C the opportunity to harm him/herself by wrapping stips of cloth around his/her neck causing his/her face to turn “blue.”

Fine: $200

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the staff are aware and understand the goals and services identified on the plan of care. Within 30 days of receipt of this order, the license holder must submit a policy that addressing how staff will verify or acknowledge when a staff transition occurs in who oversees the responsibility for monitoring the resident occurs.

Billing and Payment of the Fine

DHS will send you an invoice for the $200 fine. Payment must be made as directed on the invoice.

If you request a contested case hearing, as described below, do not pay the fine at this time. Following the contested case hearing, the Commissioner of DHS will issue a final order on this matter.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, you are personally responsible for payment.

If you do not pay the fine on or before the date specified on the invoice and you did not request a contested case hearing, as described below, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

YOUR RIGHT TO APPEAL

You have the right to appeal the fine. Your request must be in writing and clearly state that you are requesting a contested case hearing for this matter. Your request must be made before the deadlines provided below. If you do not meet this deadline, you lose your right to an administrative appeal. The timeline to appeal began when you received this order.

If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you receive this order. Please send it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you receive this order. Please bring it to:

Commissioner, Department of Human Services

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

444 Lafayette Road North

St. Paul, MN 55155

Upon DHS’ receipt of your timely appeal, your case would be scheduled for a contested case hearing in front of an Administrative Law Judge. Following this hearing, the Commissioner of DHS will issue a final order.

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.justice4mn.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 for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $200 fine for each health, safety, or supervision licensing violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (4), item (iv).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· 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.

· Minnesota Statutes, section 245A.04, subdivision 7, paragraph (d), clause (4), states that DHS shall not issue or reissue a license if the applicant, license holder, or controlling individual has an outstanding debt related to a license fee, licensing fine, or settlement agreement for which payment is delinquent.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c), clause (2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

Questions

If you have any further questions regarding this matter, you may contact Sarah Schumacher, Unit Supervisor, at 651-431-6555.

Sincerely,

Maggie Hanson, Intake and Investigations Unit Manager

Office of Inspector General

Licensing Division

Enclosure

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

doc_type: Order


report_date: November 4, 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: 202508271

Date Issued: November 4, 2025

Name and Address of Facility Investigated:

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

Disposition: Maltreatment determined.

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
651-431-6616

carla.harvieux@state.mn.us

Suspected Maltreatment Reported:

It was reported that a staff person (SP) pushed and hit an alleged victim (AV), grabbed the AV’s hair and threw him/her to the floor by his/her hair, pinned the AV to the floor, and sat on the AV and held the AV to the floor with his/her legs.

Date of Incident(s): September 4, 2025

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on September 18, 2025; from documentation at the facility and law enforcement records; and through interviews conducted with facility staff persons (P1, P2, P3, P4, and the SP), the AV, and the AV’s guardian (G). This investigator spoke with the SP by telephone, but the SP declined to complete an interview.

The facility provided services to individuals aged 12 to 19 with significant mental and behavioral health issues in a program to support families throughout the treatment process. The facility had a video recording system that recorded common areas of the facility, but the video recordings did not have sound. On campus, individuals received education services, therapies personalized to their needs, and recreational opportunities.

Facility documentation showed that the AV was diagnosed with attention deficit hyperactivity disorder and oppositional defiant disorder. The AV might become angry quickly and wanted to learn to better regulate his/her emotions. If the AV was upset, s/he might hit, kick, or bite staff persons, or pull their hair. When staff persons observed the AV becoming dysregulated, they were to encourage the AV to use coping skills to decrease his/her distress. Indications that the AV was upset included having an angry facial expression, staring, looking around the room, and/or pacing. Staying busy was important to the AV and s/he wanted staff persons to distract him/her when s/he was mad or sad. Staff persons could use permitted manual restraints with the AV if s/he posed an imminent risk of harm to him/herself or others. The AV liked to play and enjoyed one on one time with staff persons.

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

· The AV said that on the date of the incident, s/he hit the SP and attacked him/her. The SP then threw the AV to the floor, told him/her that s/he was an “f-ing bitch,” pulled the AV’s hair, and scratched him/her. During the incident, the AV was lying on his/her back on the floor with the SP leaning over him/her. At some point during the incident, the SP’s knee was on the AV’s stomach/chest. The AV was really scared and thought that the incident lasted between two to five minutes. The incident ended when P1 told the SP to “stop it.” The AV had small red marks on the inside of his/her left arm when this investigator interviewed him/her.

· P1, a milieu lead staff person, stated that the incident occurred quickly and it was difficult to remember each detail. On the date of the incident, the AV was dysregulated and there were multiple crises at the facility. The AV was engaging in property destruction, so P1 redirected the AV, and the AV hit P1, who blocked the AV’s hits. The AV then began hitting the SP and the SP said, “Get [the AV] the fuck off me,” and told the AV to, “Get the fuck away from me.” The AV continued physically aggressing toward the SP, and initially the SP blocked the AV’s hits, but then stepped toward the AV and pushed him/her. The AV did not fall, but s/he grabbed the SP’s hair and then fell backward and pulled the SP toward him/her. The SP fell forward and was leaning over the AV, with his/her legs possibly on the AV’s legs. The SP grabbed the AV’s hair and P1 attempted to get between the AV and SP to pry their hands from each other’s hair. The AV and SP each told the other to, “Stop hitting me,” and P1 instructed them to release each other’s hair. The AV released the SP’s hair, and P1 told the SP to go to the facility’s office. The SP walked toward the office, but told the AV, “You little bitch, go to fucking hell.” After that, the AV was in total dysregulation, according to P1. P1 called administrative staff persons for assistance on his/her walkie talkie, and they came to the unit to assist P1. After the incident, the VA had scratches on his/her arms from the SP’s fingernails and minor bruising that might have resulted from the incident. P1 said that if a youth attempted to hit staff persons, staff persons were to block the hits but could implement permitted restraints when safe to do so.

· P2 said that the incident began with the AV pushing the SP, but the SP “stood [his/her] ground,” and pushed the AV back. The AV and SP pulled each other’s hair and fell, then P1 intervened to separate them. P2 was especially concerned when it looked like the SP was sitting on the AV’s stomach while the AV was lying on his/her back on the floor. P2 did not observe any injuries to the AV, but there was a lot going on and s/he was unsure of the details of the incident.

· P3 and P4, who were supervisory staff persons, provided consistent information that they had each supervised the SP during the time the SP worked at the facility. P3 viewed the video recording of the incident and provided an account of the incident that was largely consistent with the account given by P1. Pushing a youth and/or pulling his/her hair were not permitted actions at the facility, and staff persons were to switch out with other staff persons or take a break if they felt stressed.

The video recording from the facility showed that the descriptions provided by P1 and the AV of the physical contact between the SP and AV during the incident, were accurate. It was unclear whether the SP sat on the AV’s chest/stomach or placed his/her knee or legs on the AV, but there was physical contact between the AV and the SP, including hitting, pushing, and hair pulling. Immediately after the incident, the AV hit the back of his/her head on a facility wall several times, but P1 quickly intervened and moved the AV away from the wall.

Records from the law enforcement agency showed that on September 4, 2025, a law enforcement officer (LEO), who was at the facility for a separate matter, was notified of the incident with the AV and the SP. The LEO met with facility administrators, viewed the video recording of the incident, and spoke with the AV. The LEO documented that the video recording showed that the AV “went after” the SP and hit him/her multiple times. The SP pushed the AV away with both hands and the AV and the SP grabbed each other’s hair, then fell to the floor, and began “struggling” with each other. P1 returned and separated the AV and the SP, then the SP stood and left the area. The LEO asked the AV about the incident and the AV told the LEO that s/he was aggressive, hit P1 first and then hit the SP again and pulled the SP’s hair. The AV told the LEO that the SP scratched the AV and told him/her, “Go to hell bitch.” The AV felt “really scared,” had a panic attack, and described the incident as painful and traumatizing. The AV had scratches on his/her upper forearms. The LEO wrote that the incident might have been against the facility’s policies and procedures and/or unprofessional, but it appeared to be self-defense and not criminal. The agency took no further action.

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

Conclusion:

A. Maltreatment:

Information was consistent that on September 4, 2025, there was physical contact between the AV and SP during which the AV hit the SP, the SP pushed the AV, and the AV and SP pulled each other’s hair. During the incident, the AV and SP fell to the floor with the AV lying on his/her back, and the SP leaning over him/her. The incident ended when the AV released the SP’s hair, and the SP went to the facility office. The SP declined to complete an interview with this investigator, but information from P1 and the AV showed that during the incident, the SP told the AV that s/he was an “f-ing bitch, told the AV, “Get the fuck away from me,” and said, “You little bitch, go to fucking hell.” In addition, the SP asked others to, “Get [the AV] the fuck off me.” After the incident, the AV had scratches on his/her arms and minor bruising that might have resulted from the incident. The AV said that s/he was really scared, described the incident as painful and traumatizing, and had a panic attack.

The law enforcement agency did not take criminal action based on the incident, and it was unknown whether the AV’s scratches/bruises were sustained during the incident. However, given that the AV was scared, felt traumatized and hit his/her head against the wall several times after the incident, and that the SP’s actions of pushing the AV and using profanity directed to the AV were non-accidental non-therapeutic overt acts, there was a preponderance of the evidence that the SP engaged in behavior which represented a substantial risk of physical or mental injury to the AV.

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

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

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

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

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

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

The SP was responsible for the care of the AV at the time of the incident. A video recording of the incident showed that the SP pushed the AV and pulled his/her hair, and information from P1 and the AV showed that the SP used profanity toward the AV during and after the incident. The SP was responsible for the maltreatment of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

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

It was determined that the substantiated abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident and did not meet statutory criteria to be determined as serious because it was unclear whether the AV sustained scratches or bruises as a result of the SP’s actions or by accidental means.

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

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate but were not followed. At the time this report was written, the SP was no longer employed 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


report_date: September 5, 2025

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

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

Report Number: 202506597

Date Issued: September 5, 2025

Name and Address of Facility Investigated:

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

Disposition: Inconclusive

License Number and Program Type:

1119782-PTRF (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 in March or April of 2025, a staff person (SP) shared details of his/her personal life with a vulnerable adult (VA), including information regarding the SP’s sexual relationships and concerns about possibly becoming a parent, the SP’s own mental health issues and self-injurious behaviors, and worries that others might see evidence of his/her self-harm on the SP’s body.

Date of Incident(s): Unknown dates in March or April of 2025

Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (2):

Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening.

Summary of Findings:

Pertinent information was obtained during a site visit conducted on August 13, 2025; from documentation at the facility; and through interviews conducted with facility staff persons (P1, P2, P3, and the SP), and the VA. P1, P2, and the SP were supervisory staff persons, and P3 was an administrative staff person.

The facility provided services to individuals aged 12 to 19 with significant mental and behavioral health issues with programs to support families throughout the treatment process. The VA turned 18 years old in mid-March of 2025, and since no specific dates were provided for the incidents with the SP, it was presumed for this report that the VA might have been 18 years old when the incidents occurred. The facility had a video recording system that recorded common areas of the facility, but the video recordings did not have sound. On campus, individuals received education services, therapies personalized to their needs, and recreational opportunities.

Facility documentation showed that the VA was diagnosed with generalized anxiety disorder and post-traumatic stress disorder and might become upset when others made comments about his/her appearance or suggested that past events might be the VA’s fault. The VA was not subject to guardianship. The VA had a history of engaging in self-injurious behavior and knew the SP from when the SP previously worked at a facility in which the VA resided. Prior to the March/April 2025 incident being known, facility supervisory/administrative staff persons decided that the relationship between the VA and the SP was non-therapeutic because of the VA’s and SP’s previous connection, and assigned the SP to work in units at the facility that limited his/her contact with the VA. The VA was social and liked to talk.

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

· The VA provided consistent information in an interview with this investigator and in the facility’s Internal Review, that on a date or dates s/he could not recall in March of 2025, the SP told the VA details about the SP’s sexual experiences, including information regarding an incident during which the SP was allegedly sexually assaulted and that the SP had concerns about possibly becoming a parent. In addition, the SP told the VA that the SP sometimes engaged in self-injurious behavior, and that the SP was concerned that his/her family members might notice that s/he harmed him/herself. The VA felt that s/he was the SP’s therapist and said it seemed that s/he was counseling the SP.

· P1 and P2 each stated in individual interviews with this investigator, that on July 22, 2025, the VA told them about the VA’s conversation/s with the SP in which the SP described his/her past sexual experiences and incidents of self-harm. The Ps listened to the VA’s concerns and thanked the VA for trusting them with the information, but were concerned that the SP did not maintain appropriate boundaries with the VA and thought that the SP’s actions caused the VA a significant amount of stress because the VA was extremely anxious and upset when s/he spoke with them about the SP and the information the SP shared. The VA told the Ps that s/he had been holding the information in for a long time and felt that s/he was previously unable to tell others about it. The Ps advised P3 of their concerns and relayed their conversation with the VA to P3. However, no information showed that the VA’s incidents of self-injurious behaviors increased when s/he had contact with the SP, and information was consistent that the facility took steps to limit the VA’s contact with the SP because of their previous relationship at another facility.

· Information P3 provided to this investigator and in the Internal Review, showed that the facility’s leadership team decided not to discuss this incident with the VA because it would likely further upset him/her. When the leadership team contacted the SP to ask him/her about the concerns, the SP did not respond and resigned his/her employment with the facility via text later that day.

· The SP told this investigator that s/he knew the VA from a facility in which s/he previously worked and in which the VA resided prior to living at the facility. The SP felt that his/her relationship with the VA was not therapeutic for him/her or the VA and said that s/he talked with facility supervisory staff persons regarding his/her the situation. Some supervisors were more supportive than others, but the SP felt that his/her concerns were generally dismissed and not taken seriously. According to the SP, s/he had a history of engaging in self-harm, and there were scars on his/her limbs that were not always covered by clothing that any reasonable person would realize occurred from incidents of self-harm that likely required medical care. The VA saw the scars and asked the SP whether the SP harmed him/herself because of the VA, but the SP reassured the VA that s/he was not the cause of any incidents of self-harm in which the SP engaged.

· The SP thought that the VA attempted to interact with the SP as if the VA was a staff person and behaved like s/he was the SP’s therapist. The SP redirected the VA but thought that the VA listened outside the staff person office when the SP discussed aspects of his/her personal life with staff persons who were also his/her friends in the community, which was how the VA obtained information regarding his/her sexual relationships and concerns about the possibility that s/he might become a parent. The SP denied that s/he intentionally shared information regarding his/her personal life with the VA.

The facility’s Boundaries, Red Flag Behavior, and Professionalism information provided to staff persons showed that each staff person was responsible for creating an environment in which all felt safe. Staff persons were to recognize professional behavior and the benefits of professional boundaries. The facility established boundaries to ensure that relationships between staff persons and individuals remained professional and recognized that when topics or discussions outside boundaries were allowed into relationships, it might become confusing for the persons involved.

If there were poor or inconsistent boundaries, therapeutic relationships might be compromised and ineffective. Mental boundary violations included dismissing/criticizing feelings, asking personal questions not appropriate for the relationship, telling others how to feel/giving unsolicited advice, emotionally dumping or oversharing, repeating confidential information, and/or making demands rather than requests. Consequences of poor boundaries included isolation, confusion, emotional lability, self-harm behaviors, disengagement, depression, emotional turmoil, or cognitive distortion. Staff persons were not to share personal information or personal struggles in hopes of relating to the individuals.

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

Conclusion:

Information was consistent from the VA, P1, P2, and the facility’s Internal Review, that in March or April of 2025, the SP shared details of his/her personal life with the VA. The VA was upset, was initially unable to share the information with others, and felt that s/he was the SP’s therapist or counselor.

P1 and P2 each stated that on July 22, 2025, the VA told them about conversations between him/herself and the SP during which the SP told the VA details of his/her personal life that were outside the boundaries of information that staff persons were permitted to share with individuals at the facility.

The Ps were concerned and discussed the matter with P3, and administrative staff persons contacted the SP to ask him/her about it, but the SP did not respond and resigned his/her position at the facility.

The SP said that his/her relationship with the VA was not therapeutic for them, and s/he talked with supervisory staff persons about it prior to the incident. The SP had visible scars that others might recognize as the result of self-harm that likely required medical care. The VA noticed the scars and asked the SP whether s/he harmed him/herself because of the VA, but the SP reassured the VA that s/he was not the cause of any incidents. However, it was possible that the VA viewed him/herself as a staff person and attempted to act as the SP’s therapist. The SP thought that the VA overheard the SP’s conversations with staff persons when s/he discussed his/her personal life, which explained how the VA knew detailed information about the SP, but the SP denied that s/he intentionally shared information about him/herself with the VA.

Facility information regarding boundaries showed that staff persons were responsible for creating safe environments. When boundaries were not observed, it might become confusing for those involved. When there were poor or inconsistent boundaries, relationships might be compromised and ineffective. Mental boundary violations included emotionally dumping or oversharing, and consequences of poor boundaries included isolation, confusion, emotional lability, self-harm behaviors, disengagement, depression, emotional turmoil, or cognitive distortion. Staff persons were not to share personal information or personal struggles with individuals.

The VA had information regarding the SP’s personal life, and it was possible that the SP shared some details of his/her actions outside the facility with the VA, which was inconsistent with facility policies and procedures, and not consistent with the role of a professional caregiver in a DHS licensed facility. However, the VA had significant mental health concerns that were being treated at the facility, it was unclear whether the VA obtained the information from the SP or overheard it when the SP talked with staff persons, and no information specifically connected the VA’s knowledge of the SP’s personal life to the VA’s self-harming behaviors. Given this, and that the SP denied that s/he intentionally shared personal information with the VA, there was not a preponderance of the evidence whether the SP engaged in conduct that caused or could reasonably be expected to cause emotional distress to the VA.

It was not determined whether abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening).

Action Taken by Facility:

The facility completed an Internal Review which determined that their policies and procedures were adequate, but were not followed when the SP shared personal information with the VA. The incident was similar to previous incidents with the SP regarding boundary concerns at the facility. At the time this report was written, the SP was no longer employed at the facility.

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

No further action taken

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


raw_content:
March 28, 2025                CERTIFIED MAIL

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 N Ste 500

Plymouth, MN 55441

License Number   1119782

Report Number   202406452

202406739

202407219

AMENDED ORDER TO PAY A FINE

NOTICE: This Amended Order To Pay A Fine supersedes an Order To Pay A Fine issued on January 10, 2025, which must be destroyed. The Amended Order to Pay a Fine corrected and removed violation numbered 6 that incorrectly identified a unit name.

Dear Michelle Murray:

The Department of Human Services (DHS) is ordering you to pay a fine of $1200 for a licensing violation at your Psychiatric Residential Treatment Facility (PRTF) under the PRTF Variance to Minnesota Rules, chapter 2960 located at 900 189th Ave NE, East Bethel, MN 55011. Details of our findings are provided below. Our next steps and your options are also detailed.

REASON FOR FINE

Violation of Staff-to-Resident Ratios

As a result of a licensing investigation conducted on September 12, 2024, a DHS licensor determined that you failed to follow the required staff-to-resident ratios.

Specifically, the license holder did not keep accurate records of staff worked to demonstrate meeting the minimum staffing requirements. Additionally, the license holder did not adjust staff ratios when residents were on increased supervision, resulting in the program not having adequate staffing to meet the residents’ needs. According to documentation provided, minimum staffing requirements were not met on the following dates and times:

1. May 4, 2024 owl unit:

a. 6:00 am to 10:00 pm;

2. May 6, 2024 owl unit:

a. 6:00 am to 2:00 pm;

3. July 9, 2024 eagle unit:

a. 6:30 am to 2:00 pm;

4. July 9, 2024 owl unit:

a. midnight to 2:00 pm; and

b. 7:30 pm to midnight;

5. July 10, 2024 owl unit:

a. midnight to 12:00 pm;

b. 1:00 pm to 9:00 pm; and

c. 10:00 pm to midnight

6. July 19, 2024 owl unit:

a. 10:30 am to 11:45 am;

7. August 14, 2024 eagle unit:

a. 2:00 pm to 10:00 pm.

Fine: $1200 ($200 per day)

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure staffing ratios meet the minimum staffing requirements, including when a resident is on increased supervision.

Rule Violated: Minnesota Variance, section R2960V.14, subparts 1, 2, and 3.

Billing and Payment of the Fine

DHS will send you an invoice for the $1200 fine. Payment must be made as directed on the invoice.

Please note, you may not avoid payment of this fine by closing, selling, or otherwise transferring the license to a third party. If this occurs, each controlling individual is personally and jointly responsible for payment. If you do not pay the fine on or before the date specified on the invoice, the Commissioner may issue a second fine, may not issue or reissue a license, or may suspend the license until the license holder pays the fine.

YOUR RIGHT TO APPEAL

The timeline for appeal runs from the date of the Order to Pay a Fine issued on January 10, 2024. On January 24, 2025, you requested a contested case hearing, and you then withdrew the appeal on January 30, 2025. As a result, the Amended Order to Pay a Fine is final and not subject to appeal.

Legal authority for this licensing action

· This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license.

· DHS may impose a $200 fine for each health, safety, or supervision licensing violation under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(4)(iii).

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(5) states that license holders may not avoid payment of a fine by closing, selling, or transferring a license.

· Minnesota Statutes, section 245A.07, subdivision 3, paragraph (c)(2), states that that the license holder shall pay the fine assessed on or before the payment date specified, and if the license holder does not do so the commissioner may issue a second fine or suspend the license until the license holder complies.

· 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, Supervisor, at 651-431-6259.

Sincerely,

Paula Halverson, Unit Manager

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


report_date: January 10, 2025

raw_content:
January 10, 2025

Michelle Murray, Authorized Agent

Nexus Family Healing

505 Highway 169 N Ste 500

Plymouth, MN 55441

License Number:   1119782

Report Numbers:   202406274

202406452

202407219

202407402

CORRECTION ORDER

Dear Michelle Murray:

On September 12, 2024 a Department of Human Services (DHS) licensor conducted a licensing investigation of your facility, Nexus East Bethel Family Healing located at 900 189th Ave NE, East Bethel, MN 55011. This investigation was conducted to determine compliance with state and federal laws and rules governing the provision of Psychiatric Residential Treatment Facilities (PRTF) under the PRTF Variance to Minnesota Rules, chapter 2960. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed.

LICENSING VIOLATIONS

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

Personnel

1. Violation: The licensor holder did not follow through with correction action steps as described in their internal reviews dated May 7, 2024 and May 8, 2024. Staff persons were not retrained on the following:

a. Approved TCI techniques (SP 3, 5, 7, 12, 17, 20, and 21);

b. Trauma informed care practices (SP 1 through 7, and 9 through 22); and

c. Maltreatment reporting (SP 1 through 22).

Statute Violated: Minnesota Statutes, section 245A.66, subdivision 1.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure a corrective action plan is completed as determined. Within 30 days of receipt of this order, submit documentation staff persons have been trained according to the corrective action plan.

Client Files

1. Violation: Four of four resident files reviewed for requirements governing individual plan of care did not meet requirements in the following ways:

a. The immediate needs assessment and preliminary plan of care was not completed within 24 hours of admission (R2);

b. The plan of care was not individualized and appropriate to the resident’s changing condition. The plan of care did not address the resident’s self-injurious behaviors, including ingestion of inedible objects (R1);

c. Plan of care with the following effective dates were not signed every 30 days:

1) May 27, 2024 (R1);

2) July 18, 2024 (R3); and

d. Plan of care with effective dates of June 26, 2024 (R1) and July 10, 2024 (R4) did not include the following:

1) The resident and legal guardian’s signature to acknowledge his/her participation in the development and revisions of the plan of care; and

2) The signature(s) and title(s) of the multidisciplinary team who completed or updated the plan of care and the signature of the mental health professional who approved the plan of care.

Rule Violated: Minnesota Variance, section R2960V.07, subpart 1, items A and B.

Repeat Violation: In a Correction Order that DHS issued on July 26, 2024, you were previously found in violation of this same requirement.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual plan of care meets compliance. Within 30 days of receipt of this correction order, submit a plan of care for one resident that demonstrates compliance.

2. Violation: Two of two resident files reviewed for requirements governing discharge planning did not meet requirements. The aftercare plan did not include the following:

a. Medical needs, including allergies (R1);

b. Clinical rationale for medications (R1 and 2);

c. Discharge diagnosis and treatment summary (R1 and 2); and

d. Prevention plan to address symptoms of harm to self or others (R1).

Rule Violated: Minnesota Variance, section R2960V.07, subpart 3, item B.

Repeat Violation: In a Correction Order that DHS issued on July 26, 2024, you were previously found in violation of this same requirement.

Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge planning meets requirements. Within 30 days of receipt of this order, submit one aftercare plan that demonstrates compliance.

Written Response Required

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

If submissions are required as part of the corrective action ordered they must be sent to your licensor by email at ginny.benson@state.mn.us or by mail at:

Commissioner, Department of Human Services

ATTN: Ginny Benson

Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

YOUR RIGHT TO REQUEST RECONSIDERATION

You have the right to request reconsideration of this order and the cited violation(s). Your request must:

· Be in writing

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

· Supply information that is accurate or more complete

· Be made before the deadlines provided below

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

Office of Inspector General

Legal Counsel’s Office

Attn: Licensing Legal Unit

PO Box 64953

St. Paul, MN 55164-0953

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

Commissioner, Department of Human Services

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

444 Lafayette Road North

St. Paul, MN 55155

Legal authority

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

Questions

If you have any further questions regarding this matter, you may contact me at 651-431-6957 or at ginny.benson@state.mn.us

Sincerely,

Ginny Benson, Senior Licensor

Licensing Division

Office of Inspector General

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

doc_type: Correction Order


report_date: December 19, 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: 202407945

Date Issued: December 19, 2025

Name and Address of Facility Investigated:

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

Disposition: Maltreatment not determined.

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
gessner.rivas@state.mn.us
651-431-3970

Suspected Maltreatment Reported:

It was reported that residents on a unit of the facility had a “sex party” and staff were unable to stop it. Two residents (AV1 and AV2) went into the courtyard and engaged in digital penetration of each other and bit each other’s necks. At the end of the party AV1 cut her/his wounds open and smeared blood on the walls and other residents drew on the walls in AV1’s blood. In addition, it was reported that an unknown resident tried to drink bleach from an unlocked laundry room and that residents have engaged in “cutting” parties with staff present.

Date of Incident(s): September 8 to 9, 2024, and possible other unknown date(s).

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 site visits conducted on October 11 and 30, 2024, from documentation at the facility; and through seventeen interviews conducted with nine staff persons (P1 – P9), two facility administrators (P10 and P11), three residents (R1, R2, R3), AV1, AV1’s guardian (G1), and AV2’s guardian (G2). AV2 declined to be interviewed. A staff person (P12), who was working the overnight shift of September 8, 2024, did not respond to this investigator’s requests for an interview.

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 facility had a video recording system that recorded common areas of the facility, but not in the bedrooms of residents; the video recordings did not have sound.

AV1 was diagnosed with personality disorder. AV1 had a history of engaging in self-injurious behavior. Facility documentation showed that AV1 liked listening to music.

AV2 was diagnosed with post-traumatic stress disorder (PTSD) and anxiety disorder. AV2 declined to be interviewed. Facility documentation showed that AV2 liked playing video games and sports.

The facility’s Suicidal Ideation and Gesture Protocol showed that when youths were shadowed by staff persons, they were to be close enough to the residents to initiate a hold/intervention if needed, which meant that staff persons were to be in the same room with the resident, have eyes on the resident or have continued verbal contact with the resident when s/he was in the bathroom or shower. The shadowed resident was not to remain in his/her bedroom with the door closed unless s/he was changing clothes, and then staff persons were to keep verbal contact with him/her. When shadowed residents slept, staff persons were to remain awake in the hallway outside their bedrooms, and they were not allowed to use facility headphones when staff persons shadowed them for self-injurious behavior.

The facility did not have a written policy or procedure regarding residents engaging in sexual behavior with one another. P10 stated that the facility sought guidance from DHS and law enforcement. Staff persons were to ascertain if the residents had consented to such behavior, if one resident had not consented then staff persons had to intervene, staff persons had to separate residents if they began to remove clothing.

Regarding the “sex party” and AV1 and AV2 having sexual contact:

The report did not detail which residents were involved in the alleged sex party, but that AV1 and AV2 engaged in digital penetration of each other and that some residents did not go to bed until 5 a.m. Video footage provided by the facility from the night of September 8, 2024, only showed AV1 and AV2, no other residents appeared to have been involved in any sexual activity. Video footage timestamped 9 p.m. on September 8, 2024, showed AV1 and AV2 going outside to the facility’s fenced in courtyard closely followed by P2 and P12. At times P1 could be seen on video footage assisting as well. Video footage showed no other residents engaged in any kind of sexual behavior. Video footage at one point showed that AV1 and AV2 went behind some bushes for approximately one minute while P2 and P12 stood a few feet away on the other side of the bushes. AV1 and AV2 remained outside for approximately 40 minutes before returning inside where they remained in a hallway where they engaged in hugging, kissing, and what appeared to be biting each other on the neck. In all videos provided by the facility, staff persons remained within close proximity of AV1 and AV2. There was no video provided showing that any residents remained awake until 5 a.m.

AV1 stated that sometimes residents got together and stayed up late either in the hallway of a unit or in a resident’s room often when residents were struggling and need a distraction. AV1 recalled that s/he and AV2 went to the courtyard. Staff persons attempted to verbally redirect them. AV1 confirmed that there was digital penetration while they were behind some bushes in the courtyard.

P10 and P11 each stated that the residents that were in the courtyard, AV1 and AV2, engaged in kissing and touching over clothing. P11 was contacted by staff persons on duty and provided tips on what to do about the situation. Staff persons were instructed to verbally redirect residents engaging in sexual behavior, make them “uncomfortable” with verbal redirection so they would stop, and try to position themselves between the residents, and separate the residents if the behavior was nonconsensual or if clothing was removed. AV1 and AV2 had been dating but had been separated to different units of the facility and would find ways to get together which involved stealing badges from staff persons and entering the other’s unit. Staff persons maintained supervision of AV1 and AV2 while in the courtyard and did not see digital penetration, the facility reviewed video footage which showed staff persons talking to AV1 and AV2.

P1 stated that AV2 had taken a staff person’s badge and went to AV1’s unit. On September 8, 2024, when AV1 and AV2 went out into the courtyard, P1 instructed staff persons follow them. P1 stated that staff person were supposed to try to make the residents feel “uncomfortable” when they engaged in sexualized behavior with one another to attempt to stop the behavior.

P2 stated that s/he was asked to monitor AV1 and AV2 when they went outside. Facility practice was that staff persons could not restrain residents for engaging in sexualized behavior, but P2 notified an unknown manager and P1. P2 attempted to verbally redirect AV1 and AV2 from their behavior. AV1 and AV2 said they were consenting to their behavior. P2 recalled that the incident continued for four to six hours. P2 stated that AV1 and AV2 may have engaged in digital penetration while they were behind the bushes but could not tell.

P3-P9 each stated that they had no direct knowledge of the events from September 8-9, 2024.

G1 and G2 were told that staff persons could not stop the residents from engaging in sexualized behavior.

Regarding AV1’s self-harm, a resident accessing bleach, and residents engaging in “cutting parties” in the presence of staff:

The report alleged that at the end of the sex party, AV1 cut his/her wounds open and smeared blood on the walls and other residents dew on the walls with the blood.

Video footage provided by the facility showed no resident engaging in acts of self-harm or engaging in writing on the walls on the night of September 8 to 9, 2024, which was when the sex part was alleged to have occurred.

AV1 stated that there had been many occasions in which s/he smeared her/his blood on the facility walls and most of the times s/he engaged in such acts of self-harm were in front of a staff person when AV1 found glass to use.

P10 and P11 noted that staff persons were to try and redirect residents who were attempting self-harm and if the self-harm posed an imminent risk, they were to call 9-1-1 and implement a restraint. Other staff persons, P3-P9 provided consistent information regarding what staff persons were supposed to do.

R1, R2, and R3 provided consistent information that staff persons would try to verbally redirect residents who engaged in self-harm that occurred in front of staff persons.

Regarding a resident attempting to drink bleach or residents engaging in “cutting parties,” incident reports from September 2024 contained no such information regarding either of these occurring. P1-P11 did not have any knowledge of such incidents either.

G1 and G2 shared concerns about the facility’s supervision of residents. Many residents had obtained glass shards from a bathroom wall at the facility which they used in self-harming which led to residents requiring medical attention numerous times due to acts of self-harm. (Note: This concern was investigated by DHS previously.)

All staff persons interviewed were trained on the Maltreatment of Minors Act and the facility’s policies and procedures regarding restraints and supervision.

Conclusion:

It was reported that residents had a “sex party,” AV1 and AV2 had sexual contact, some residents stayed up until 5 a.m., and at some point AV1 cut him/herself, smeared the blood on the walls, and residents drew in it.

The date of the alleged party was September 8 to 9, 2024. Video and information from interviews showed that AV1 and AV2 went to the courtyard and engaged in sexualized behavior but there were no other residents present, and staff persons were near AV1 and AV2 attempting to verbally redirect them for the duration of the incident. AV1 stated there was digital penetration between AV1 and AV2 but staff persons did not see it as it likely happened when AV1 and AV2 went behind some bushes. When AV1 and AV2 went back inside, they continued sexualized behavior and staff persons continued to be near and verbally redirect them.

There was no information that AV1 cut him/herself that night and smeared it on the walls and other residents drew in it. AV1 stated that in the past s/he had cut him/herself and smeared it on the walls in front of staff persons.

It was also reported that residents had cutting parties in front of staff persons. There was no additional information regarding which residents or dates this occurred. Information was consistent that residents at the facility engaged in acts of self-harm, often in the presence of staff persons. All staff persons and residents interviewed confirmed that when a resident engaged in self-harm, staff persons would attempt to verbally redirect residents. Staff persons were instructed to monitor such situations and intervene when a resident’s act of self-harm posed an imminent threat to the resident.

With respect to residents engaging in sexual behavior, staff persons were instructed to try to verbally redirect residents, ascertain if there was consent from the residents to engage in such behavior and physical intervene if there was not or if residents began to remove the clothing.

It was also reported that a resident accessed and drank bleach but there was no information regarding which resident or date of occurrence, and no one had information whether this occurred.

Although AV1 and AV2 had sexual contact and AV1 stated that s/he had in the past cut him/herself in front of staff and smeared blood on walls, given that during the September 8 to 9, 2024, incident information was consistent that AV1 and AV2 were the only residents engaged in sexual activity and staff persons remained near them providing verbal redirection, that there was no information that that night AV1 smeared blood and others drew in it, and that there was no specific details or information whether any resident drank bleach or that there were cutting parties, there was not a preponderance of the evidence that there was a failure to supply children with necessary care or failure to protect children from serious danger to their physical or mental health.

It was not determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so).

Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (b), the investigative data in this report will be maintained by the Department of Human Services for a period of five years.

Action Taken by Facility:

The facility conducted an Internal Review and determined that its policies and procedures were adequate, but staff persons would receive more training on how to deal with increased sexualized behavior.

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

No further action taken.

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/


summary: CORRECTION ORDER

raw_content:
April 23, 2025

Michelle Murray

900 189th Ave NE

East Bethel, MN 55011

RE:  Report No. 202407409

Nexus East Bethel Family Healing

License No. 1119782

Dear Michelle Murray:

CORRECTION ORDER

An investigation of Nexus East Bethel Family Healing was completed regarding report number 202407409 which alleged violation of Minnesota Statutes, section 260E.06. This maltreatment allegation concerned neglect. The disposition of the investigation report is Maltreatment not determined. One violation was noted.

VIOLATION AND CORRECTION ORDER

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

Citation: Minnesota Statutes section 245A.04, subdivision 14, (b), (1-3).

Violation: The license holder failed to monitor implementation of policies and procedures by program staff persons.

Two staff persons (P1 and P2) did not provide a child (C) with supervision as required by the facility’s Suicidal Ideation and Gesture Protocol. The C was unsupervised in his/her bedroom for about two minutes and attempted to harm him/herself.

Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure that basic services are provided as required.

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

Commissioner

Minnesota Department of Human Services

c/o Licensing Division

PO Box 64242

St. Paul, MN 55164-0242

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

If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Hannah Horsch, at 651-431-6270.

Sincerely,

Carla Harvieux, Investigator

Office of Inspector General

Licensing Division

carla.harvieux@state.mn.us

651-431-6616

Enclosure

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