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November 4, 2025 Michelle Murray, Authorized Agent Nexus Gerard Family Healing 505 Highway 169 North Plymouth MN, 55441 License Number: 831080 (CRF) Report Numbers: 202407792, 202502585, and 202506518 CORRECTION ORDER Dear Michelle Murray: On September 15 through 18, 2025, Department of Human Services (DHS) licensors conducted a licensing review and investigation at your facility, Nexus Gerard Family Healing located at 1111 28th Street Northeast, Austin, Minnesota, 55912. This review was conducted to determine compliance with state and federal laws and rules governing the provision of children's residential facilities under Minnesota Rules, parts 2960.0010 through 2960.0120, group residential facilities under Minnesota Rules, 2960.0130 through 2960.0220, and residential mental health treatment under Minnesota Rules, 2960.0580 through 2960.0700, restrictive techniques standards under Minnesota Rules, part 2960.0710, with a residential program certification as a qualified residential treatment program under Minnesota Statutes, section 245A.25. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Physical Plant 1. Violation: The license holder’s physical environment did not provide for the comfort, privacy, and dignity of residents. Units Chateau and Cherbourg did not have window coverings on windows in the residents’ rooms. Rule Violated: Minnesota Rules, part 2960.0110, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of the physical plant. Practices 2. Violation: The license holder did not have documentation to demonstrate that an internal review was completed for alleged maltreatment of a minor for incident occurring on July 18, 2025. Statute Violated: Minnesota Statutes, section 245A.66. Corrective Action Required: Immediately and on an ongoing basis, the license holder must comply with all requirements of maltreatment reporting. Within 30 days receipt of order, submit documentation of the internal review completed for the incident occurring on July 18, 2025, that demonstrates compliance with all requirements. 3. Violation: The license holder did not have documentation that they conducted an annual evaluation of the program’s strengths and weaknesses according to performance indicators identified in Minnesota Rules, part 2960.0060, subpart 3, item A, for calendar years of 2023 and 2024. Rule Violated: Minnesota Rules, part 2960.0060, subpart 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the annual evaluation of the program’s strengths and weaknesses meets all requirements. 4. Violation: The license holder’s provision of weekly clinical supervision did not meet requirements in two of two weeks reviewed. Clinical supervision documentation indicated a mental health professional did not provide clinical supervision to staff providing program services to a resident for the following: a. For the weeks of July 2 through 8 and July 3 through 9, 2025, 27 staff members didn’t receive clinical supervision; and b. For the weeks of September 3 through 9 and September 4 through 10, 2025, 14 staff members didn’t receive clinical supervision. Rule Violated: Minnesota Rules, part 2960.0630, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure clinical supervision meets all applicable requirements. Within 30 days receipt of order, submit a plan that outlines how the program will maintain compliance with requirements. Personnel 5. Violation: One of fifteen personnel files reviewed for requirements governing background studies did not meet requirements. The license holder did not notify the commissioner or initiate a new background study for a staff person who underwent a legal name change (personnel file numbered 16). Statute Violated: Minnesota Statutes, section 245C.04, subdivision 7. Corrective Action Required: You must comply with the background study requirements in Minnesota Statutes, chapter 245C. Within 10 days from receipt of this order, submit written documentation to your licensor detailing how compliance has been achieved and how compliance will be maintained in the future. 6. Violation: One personnel file reviewed for staff qualifications did not meet requirements. The license holder did not have documentation showing that the staff’s professional licensure was current (personnel file numbered 15). Rule Violated: Minnesota Rules, part 2960.0150, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that documentation in personnel files meets all applicable requirements. 7. Violation: Eight of eight personnel files reviewed for orientation training did not meet requirements in the following ways: a. The license holder did not have documentation to demonstrate that staff members completed the following orientation trainings before having unsupervised direct contact with residents: i. Emergency procedures (personnel files numbered 3, 4, 5, 7, and 11); ii. Maltreatment of minors reporting requirements (personnel files numbered 3 and 7); iii. Cultural diversity and gender sensitivity (personnel files numbered 3, 4, 5, 7, and 11); iv. General and special needs, including disability needs, of residents and families served (personnel files numbered 2, 3, 4, 5, 7, 11, 12, and 13); v. Data practices regulations and issues (personnel file numbered 11); vi. Concepts of trauma-informed care and how to provide services to each youth according to those concepts (personnel file numbered 7); and vii. Impacts of each youth’s culture, race, gender, and sexual orientation on the youth’s behavioral health and traumatic experiences (personnel files numbered 3, 4, 5, 7, and 13) b. Medication assistance training provided by the registered nurse was not placed in the unlicensed staff person’s personnel file (personnel files numbered 4 and 11); c. The license holder did not have documentation to demonstrate that staff received an orientation to vulnerable adults maltreatment reporting requirements and definitions (personnel files number 3 and 7); d. The license holder did not have documentation to demonstrate that staff members completed training on the following items during the first 45 calendar days of employment, and before assuming sole responsibility for the care of residents: i. Residents’ rights (personnel files numbered 3, 4, 5, 7, 11, and 12); and ii. Problems and needs of residents with severe emotional disturbance and their families (personnel files numbered 3, 4, 7, 11, and 12) e. The license holder did not have documentation that they provided training to program staff related to their duties in implementing the program's policies and procedures (personnel file numbered 13). Statute and Rule Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph b, 245A.25, subdivision 3, paragraph b, and 245A.65, subdivision 3 and Minnesota Rules, parts 2960.0080, subpart 11, item D, subitem 5, 2960.0100, subpart 3, item A, and 2960.0650, subpart 1, items B and G. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure orientation training meets all applicable requirements. Within 30 days receipt of order, submit documentation of a newly oriented staff member that demonstrates compliance with all orientation requirements. 8. Violation: Seven of seven personnel files reviewed for ongoing training did not meet requirements in the following ways: a. The license holder’s documentation did not demonstrate that the staff person received training annually for these topics: i. Vulnerable adults maltreatment reporting requirements and definitions in the following calendar years: 1. 2023 (personnel files numbered 8 through 10 and 15); and 2. 2025 (personnel files numbered 6, 8, 9, 14 and 15) ii. The license holder’s Program Abuse Prevention Plan in the following calendar years: 1. 2023 (personnel files numbered 10 and 15); 2. 2024 (personnel files numbered 6, 9, and 14); and 3. 2025 (personnel files numbered 8, 10, and 15) iii. All internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services in the following calendar years: 1. 2023 (personnel files numbered 8, 9, 10, and 15); and 2. 2025 (personnel files numbered 6, 8, 9, 11, 14, and 15) iv. Maltreatment of minors reporting requirements in the following calendar years: 1. 2023 (personnel files numbered 8, 9, 10, and 15); and 2. 2025 (personnel files numbered 6, 8, 9, 11, 14, and 15) v. The impacts of culture, race, gender, and sexual orientation on individual youth’s behavioral health and experiences of trauma in the calendar year 2025 (personnel files numbered 9, 14, and 15) b. The license holder did not review the emergency plan with staff at least once every six months (personnel files numbered 4 through 11, 14 and 15). Statute and Rule Violated: Minnesota Statutes, sections 245A.25, subdivision 3, paragraph h, 245A.65, subdivision 3, 245A.66, subdivision 4, Minnesota Rules, parts 2960.0080, subpart 14, and 2960.0100, subpart 3, item A. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure ongoing training meets all applicable requirements. Residents 9. Violation: Two of seven resident files reviewed for admission procedures did not meet requirements. The inventory of the resident’s personal property was not signed by the resident or two staff members if the resident refused to sign (resident files numbered 1 and 5). Rule Violated: Minnesota Rules, part 2960.0070, subpart 4. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that admission procedures meet all applicable requirements. 10. Violation: One resident file reviewed for requirements governing individual abuse prevention plans (IAPP) did not meet requirements. The IAPP did not contain an individualized assessment of the person’s susceptibility to abuse by other vulnerable adults (resident file numbered 4). Statute Violated: Minnesota Statutes, section 245A.65. subdivision 2, paragraph b. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that IAPPs meet all applicable requirements. 11. Violation: Seven of seven resident files reviewed for requirements governing admission screenings did not meet requirements in the following ways: a. The health screening did not occur within 24 hours of admission (resident file numbered 7) and did not note the resident’s vulnerability to abuse (resident files numbered 1 through 5, 7, and 8); b. The resident was not screened for vulnerabilities to abuse and sexually abusive behaviors using an instrument approved by the commissioner. The tool used did not include the following (resident files numbered 1 through 5, 7, and 8): i. If the child has a history of vulnerability such as being teased, picked on, or other indications of potential safety issues with other residents; ii. If the child has a history of boundary violations; or iii. If the child’s history indicates the need for special precautions or particular staffing patterns in the facility. c. The gender-based needs screening was not completed (resident files numbered 1, 2, 5, 7, and 8); d. The screenings did not include documented inquiries and the results of the inquiries regarding the degree to which the resident's family desires to be involved during the resident's stay at the facility (resident files numbered 3 and 7); and e. The license holder did not complete a screen for trauma by completing a trauma-specific screening tool with each youth upon the youth’s admission. The screening completed by the program was completed after admission (resident files numbered 1 through 4, 7, and 8). Statute and Rule Violated: Minnesota Statutes, section 245A.24, subdivision 3, paragraph c and Minnesota Rules, part 2960.0070, subpart 5, items A, B, C, and D. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure admission screenings meet all applicable requirements. Within 30 days receipt of order, submit documentation of a newly admitted resident that demonstrates compliance with all admission screening requirements. 12. Violation: Two of six resident files reviewed for requirements governing program services did not meet requirements. There was not documentation to demonstrate that the license holder contacted and facilitated outreach to the residents’ siblings (resident files numbered 3 and 4). Statute Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph g. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program services meet all applicable requirements. 13. Violation: Seven of seven resident files reviewed for requirements governing treatment plans did meet requirements in the following ways: a. There was not documentation that the license holder assigned the resident to a designated staff person to ensure regular face-to-face contact and to monitor and assist the resident to implement the treatment plan (resident file numbered 2 and 3); b. The treatment plan was not completed within ten days of admission (resident files numbered 1 through 5, 7, and 8); c. The treatment plan did not include a schedule for accomplishing treatment goals and objectives (resident files numbered 1 through 5, 7, and 8); d. Psychotropic medication was not included in the treatment plan for a resident prescribed a psychotropic medication (resident file numbered 2); e. A mental health professional did not sign the treatment plan (resident file numbered 1); and f. The treatment plan did not include how the program integrates family members into the treatment process for the youth, including after the youth’s discharge from the program, and how the program maintains the youth’s connections to the youth’s siblings (resident file numbered 3). Statute and Rule Violated: Minnesota Statutes, section 245A.25, subdivision 4, paragraph h, Minnesota Rules, parts 2960.0180, subpart 2, item B, 2960.0600, item A, 2960.0620, subpart 1, item A, and 2960.0630, subpart 3, item B. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment plans meet all applicable requirements. Within 30 days receipt of order, submit a treatment plan that demonstrates compliance with all requirements. 14. Violation: Five of seven resident files reviewed for requirements governing health care did not meet requirements. The license holder did not have documentation to demonstrate if all scheduled medications were administered on the following dates: a. March 19 and 22, 2025 (resident file numbered 2); b. March 26, May 7, 2025, and October 5, 2024 (resident file numbered 3); c. October 7, 2024, and January 13 and 16, 2025 (resident file numbered 4); d. August 19, 2025 (resident file numbered 7); and e. December 24, 2024 (resident file numbered 8). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item E. Corrective Action Required: Immediately and on an ongoing basis, the license holder must unsure that the provision of health care services meets all requirements. 15. Violation: Seven of seven resident files reviewed for requirements governing psychotropic medications did not meet requirements in the following ways: a. Documentation did not demonstrate that the license holder checked for side effects at least weekly for the first six weeks after a resident began taking a new psychotropic medication and at least quarterly thereafter (resident files numbered 1, 2, 4, 5, and 7); b. Documentation did not demonstrate that the license holder monitored for tardive dyskinesia at least every three months for a resident prescribed an antipsychotic medication (resident files numbered 3 and 5); and c. The license holder reported they are not conducting monthly and quarterly psychotropic medication reviews to the requirements in Minnesota Rules, part 2960.0620, subpart 5, and there was no documentation in the resident file (resident files numbered 1 through 5, 7, and 8). Rule Violated: Minnesota Rules, parts 2960.0620, subparts 2 and 5. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that the use of psychotropic medications meets all applicable requirements. Within 30 days receipt of order, submit documentation of one resident’s monthly psychotropic medication reviews that demonstrates compliance with all requirements. 16. Violation: Seven of seven resident files reviewed for requirements governing informed consent did not meet requirements (resident files numbered 1 through 5, 7, and 8). Informed consent documentation did not include the following required components: a. The level to which the medication is to change the symptoms and behavior and an indication of the method used to determine the expected benefits; and b. The pharmacological and nonpharmacological treatment options available and the course of the condition with and without treatment options. Rule Violated: Minnesota Rules, chapter 2960.0620, subpart 7, items A and C. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that informed consents meet all applicable requirements. Within 30 days receipt of order, submit documentation of one resident’s informed consents that demonstrates compliance with all requirements. 17. Violation: One of three resident files reviewed for requirements governing the use of time out procedures did not meet requirements. Documentation reviewed in milieu notes detailed an instance on July 19, 2025, where time-out was used, but the documentation required following the use of a time-out was not completed (resident file numbered 7). Rule Violated: Minnesota Rules, chapter 2960.0080, subpart 5, item D. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that time out procedures meet all applicable requirements. 18. Violation: Five of five resident files reviewed for requirements governing the use of restrictive procedures did not meet requirements in the following ways: a. Documentation did not demonstrate that the staff person who implemented the restrictive procedure documented its use immediately after the incident concluded on restrictive procedures that occurred on the following dates: i. August 29, 2025 (resident file numbered 1); ii. September 13 and 15, 2024 (resident file numbered 3); iii. January 12, 2025 (resident file numbered 4); iv. April 6 and 12 and August 17, 2025 (resident file numbered 5); and v. and July 18, 24, 25, and 26, 2025 (resident file numbered 7). b. Through reviewing video footage and conducting staff interviews as part of a licensing investigation, it was determined that a restrictive procedure that occurred on July 18, 2025, did not meet requirements in the following ways (resident file numbered 7): i. The physical holding technique was not included in the license holder’s approved restrictive procedures plan. Video footage of the physical holding showed a staff person’s knee and shin placed across the resident’s stomach and chest; ii. The resident was not treated respectfully throughout the procedure. Video footage of the physical holding showed a staff person stepping over the resident and grazing the resident’s face with their foot; iii. An administrative review was completed following the use of physical holding, but it did not identify that the rule standards governing the use of restrictive procedures were not met; iv. Information obtained during investigative interviews indicated that a staff person involved with the physical hold, who did not treat the resident respectfully, required additional training. There was no documentation to demonstrate any additional training was completed. Rule Violated: Minnesota Rules, part 2960.0710, subparts 6, items J and K and 10, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that restrictive procedures meet all applicable requirements. Within 30 days receipt of order, submit documentation that personnel file numbered 7 received additional training on the use of restrictive procedures. 19. Violation: One of six resident files reviewed for requirements governing discharge procedures did not meet requirements. The resident file did not contain a signed receipt of personal property (resident file numbered 5). Rule Violated: Minnesota Rules, part 2960.0090, subpart 3. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge procedures meet all applicable requirements. 20. Violation: Four of four resident files reviewed for requirements governing transition services plans did not meet requirements. There was not documentation to demonstrate that a copy of the plan was given to the resident upon discharge (resident files numbered 2, 3, 4, and 8). Rule Violated: Minnesota Rules, part 2960.0190, subpart 1, item A. Repeat Violation: In a Correction Order that DHS issued on October 7, 2022, you were previously found in violation of this same rule. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transition services plans meet all applicable requirements. 21. Violation: Three of four resident files reviewed for requirements governing discharge documentation did not meet requirements. The license holder did not have documentation of the extent to which the resident's stay in the facility met the objectives identified in the resident's treatment plan (resident files numbered 2 through 4). Rule Violated: Minnesota Rules, sections 2960.0140, subpart 2, and 2960.0190, subpart 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that discharge documentation meets all applicable requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at Hannah.Horsch@state.mn.gov or by mail: Commissioner, Department of Human Services ATTN: Hannah Horsch Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General, Legal Counsel’s Office - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6270 or at Hannah.Horsch@state.mn.us. Sincerely, Hannah Horsch, Licensor Licensing Division Office of Inspector General
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