Minnesota

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MALTREATMENT INVESTIGATION MEMORANDUM

Office of Inspector General, Licensing Division Public Information

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

Report Number: 202509289

Date Issued: February 19, 2026

Name and Address of Facility Investigated:

JD Home Healthcare

7312 Lyndale Avenue South Richfield, MN 55423

JD Home Healthcare

3784 County Road 8 Southeast Saint Cloud, MN 56304

Disposition: Maltreatment determined as to neglect and physical abuse of an alleged victim (AV) by one staff person (SP3), and neglect of the AV by two staff persons (SP1 and SP2).

License Number and Program Type:

1128752-H_CRS (Home and Community-Based Services-Community Residential Setting) 1083476-HCBS (Home and Community-Based Services)

Investigator(s):

Thomas Nixon/Beth Virden

Minnesota Department of Human Services Office of Inspector General, Licensing Division PO Box 64242

Saint Paul, Minnesota 55164-0242 651-431-2155

Suspected Maltreatment Reported:

It was reported that staff persons (SP1, SP2, and SP3) initiated an emergency use of manual restraint (EUMR) on an alleged victim (AV) when the AV was walking away from staff and there was not an imminent threat to anyone’s safety, and that during the EUMR, staff knelt on the AV’s hands and twisted the AV’s arms.

Date of Incident(s): September 28, 2025

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

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

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

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

Summary of Findings:

Pertinent information was obtained during a site visit conducted on October 21, 2025; from documentation at the facility; and through interviews conducted with the AV’s guardian (G), the AV’s case manager (CM), the AV’s family member (FM), facility staff persons (SP1 and SP2), and supervisory staff persons (P1 and P2). The DHS investigator also interviewed the AV; however, the AV provided limited information. The DHS investigator contacted another staff person (SP3); however, SP3 declined to be interviewed. During SP1’s interview, SP1 asked to watch the camera footage and for an interpreter to be present. At that point, the interview was stopped but when the DHS investigator contacted SP1 to reschedule with an interpreter, SP1 declined to be interviewed further.

The AV’s support plans, including Individual Abuse Prevention Plan, stated the following:

· At the time of the incident, the AV was 17 years old. The AV liked listening to music, going to school, and making friends, and was described as “fun, kind, in tune with others, empathetic.”

· The facility was a single-family home where the AV was the sole resident. The facility provided the AV with three staff persons during daytime hours and two staff during nighttime hours. Staff were to provide physical assistance and support to the AV as needed. [Note: The facility had a variance to provide Home and Community-Based Services to the AV.]

· The AV had a “very unstable and traumatic childhood” and needed consistent, trusted people in his/her life. The AV was susceptible to abuse from others and might struggle regulating or expressing his/her emotions and/or dealing with people who were verbally or physically aggressive. The AV might aggress towards others, which might include hitting and kicking. Staff were to intervene when needed and to encourage the AV to leave unsafe situations.

· The AV’s diagnoses included intellectual disabilities.

The facility’s camera footage and P2’s incident report provided the following information:

· P2’s incident report stated that on/or around October 3, 2025, an unidentified staff prompted P2 to review the facility’s camera footage regarding an EUMR (emergency use of manual restraint) on September 28, 2025, when SP1, SP2, and SP3 were working with the AV. P2 watched the camera footage

and saw that, between approximately 9:20 and 10 a.m., SP1’s, SP2’s, and SP3’s conduct towards the AV included an “inappropriate use of EUMR, verbal and physical maltreatment … and false reporting … to both (facility) management and the police.”

· The camera footage showed that at 9:22 a.m., the AV picked up the facility’s cellphone and declined to give it back when asked by staff. SP3 told the AV that s/he lost the privilege to use the phone. [Note: Throughout the incident, SP1-SP3 frequently spoke among themselves in front of the AV in a language other than English and laughed. The AV did not appear to speak or understand the language. The staff would then periodically say something in English directed at the AV, like, “Stop” or “You need to….”]

· At 9:28 a.m., SP1 grabbed the cellphone out of the AV’s hand. The AV grabbed at SP1 and SP1 pushed the AV away with one or both hands and SP2 stepped between the AV and SP1. The AV walked into his/her bedroom while SP1-SP3 sat on a living room couch and laughed. The AV walked into the living room and stated, “It’s not fucking funny,” and “Shut up.” SP3 responded to the AV, “You shut up” and SP2 laughed. The AV lifted his/her foot and touched SP1’s shin. [Note: The AV’s movement with his/her foot was slow and there was no backswing or obvious use of force or audible noise. SP1’s clothing moved, which indicated the AV’s foot contacted the clothing. SP1 did not express obvious pain and did not move his/her leg.] SP1 told the AV, “Do not touch me” and SP2 laughed.

· The AV walked away, into the front entryway, and SP1 followed. The AV swung his/her foot toward SP1’s shin. [Note: The AV’s movement with his/her foot was fast. SP1’s clothing moved, which indicated the AV’s foot contacted the clothing. SP1 did not express obvious pain and did not move his/her leg.] The AV turned and started walking away from SP1.

· At 9:36 a.m., SP1 took several steps towards the AV, grabbed the AV’s arms from behind, and pushed the AV against a wall. SP2 and SP3 ran into the room. SP3 grabbed one or both the AV’s feet, which caused the AV to fall backward onto the floor with SP1 still holding the AV’s arms behind the AV’s back. SP2 lay on top of the AV’s legs, which were moving back and forth. SP2 was facing the AV’s feet and had his/her back turned to the AV’s upper body, SP1, and SP3.

· The AV and SP1 were lying on their sides on the floor and at this point, the AV was motionless. SP1 abruptly rocked his/her own body into a sitting position, which lifted the AV’s upper body. However, the AV could not sit fully upright because SP2 was continuing to hold the AV’s legs in a side-lying position while SP1 attempted to pull the AV’s upper body into an upright sitting position. The AV made a shrieking, unintelligible, “Ah,” noise. SP2 repositioned his/her grip, which allowed the AV to reposition his/her legs and sit upright with SP2. The AV abruptly jerked his/her head backward more than once, and staff told the AV, “Stop headbutting.” SP1 pressed the top of his/her own head into the base of the AV’s head and neck in an apparent attempt to stop the AV from headbutting. SP2 repeatedly laughed.

· SP3 moved behind SP1 and pulled the AV’s hands further backward behind SP1’s back. At least once, SP3 attempted to kneel on the AV’s left hand but the AV pulled it out of the way. The AV told the staff that they were hurting him/her. [Note: The camera footage did not show any staff making obvious movements to reposition or minimize the AV’s pain.] At various points and more than once, SP1 and SP3 each let go of the AV and checked a cellphone or adjusted their own positioning and then re-grabbed the AV in the hold while the AV sat motionless.

· At 9:41 a.m., SP1-SP3 abruptly released the AV, and each had to maneuver around the AV to stand while the AV sat motionless on the floor. SP1 pushed the AV out of the way to stand. SP3 called 9-1-1 and told the dispatcher that the AV was “hitting staff non-stop.” At this point, the AV was sitting motionless on the floor with SP1 and SP2 standing around him/her. SP1 was within arm’s reach of the AV and the AV repeatedly swung his/her arm backward towards SP1’s shin. [Note: SP1’s clothing moved and there were audible noises, which indicated the AV’s hand contacted SP1’s shin. SP1 moved his/her leg out of the way but did not express obvious pain or walk away.] SP1 told the AV, “Stop hitting me.” SP1 then moved to sit on a bottom step within the same space a few feet away from the AV. The AV crawled over to SP1 and repeatedly punched at SP1’s shin. [Note: SP1’s leg moved in response to each punch. SP1 did not express obvious pain and did not move or walk away.] After about 90 seconds, SP1 stood and walked a few feet on the other side of the AV. The AV again crawled towards SP1.

· At 9:48 a.m., SP1 knelt and grabbed the AV’s arms pulling them behind the AV’s back. SP1 then hyperextended his/her own back, which in turn hyperextended the AV’s back and allowed SP2 to pull the AV’s legs out from under him/her. SP2 again lay on top of the AV’s legs and had his/her back turned to the AV’s upper body, SP1, and SP3. SP3 again grabbed the AV’s hands behind SP1’s back and appeared to pull the AV’s arms upward or outward and SP3 kneeled on the AV’s hands. The AV sat motionless while this occurred but made statements, like, “You’re hurting me.” [Note: The camera footage did not show any staff making obvious movements to reposition or minimize the AV’s pain.]

· At various points and more than once, SP1 and SP3 each let go of the AV and checked a cellphone or adjusted their own positioning and then re-grabbed the AV in the hold while the AV sat motionless. At an unstated time, SP3 again called 9-1-1 telling the dispatcher that the AV was continuing to hit staff.

· At 9:52 a.m., SP1-SP3 abruptly released the AV, and each had to maneuver around the AV to stand while the AV sat motionless. The AV began repeatedly striking his/her head against a wall, which made an audible sound. SP1 initially grabbed the AV’s shoulders but then let go. SP1-SP3 stood, speaking in a language other than English, while the AV struck his/her head on the wall more than once.

· At 9:57 a.m., the police arrived and brought the AV to an emergency room for evaluation.

P1 and P2 provided the following information:

· P2 said that SP1’s, SP2’s, and SP3’s conduct was “very unsettling.”

· P1 said that the AV had a history of becoming dysregulated which might lead to aggression and impulsivity. The conduct observed on video by SP1, SP2, and SP3 was “absolutely not” consistent with training. SP3 told the AV that the AV lost the privilege to use the phone which “likely escalated” the situation and was not true. The AV could use the phone when s/he wanted to use the phone. [Note: The AV’s right to access a phone was not restricted.] P1 said that the AV’s conduct, including kicking SP1, was “not an emergency.” SP1 had multiple opportunities to walk away and/or the other staff should have switched out with SP1.

· P1 and P2 each said that at one point the AV went into his/her bedroom and appeared calm, but no staff followed or attempted to “engage” or “debrief” with the AV about what happened. Instead, staff sat on the couch together and appeared to be laughing. At one point, SP1 pushed the AV, which was not allowed. At another point, the AV was walking away when SP1 grabbed the AV’s arms and “threw [the

AV] up against the wall.” SP2 repeatedly laughed and continued to lay across the AV’s legs even when the AV was motionless and “wasn’t even kicking.” SP3 kneeled on the AV’s hands and hyperextended the AV’s arms. More than once the AV called out in pain, but no one released or intervened to minimize the AV’s pain. In addition, no one communicated instructions to the AV.

· The AV did not sustain injuries from the incidents.

SP1 and SP2 provided the following information:

· SP1 and SP2 each said that P1 told them the AV could only use the phone once per day to call the FM. The AV had a history of getting “pissed and mad” and fighting and hitting staff. SP1 and SP2 were trained to talk to the AV to calm him/her. If the AV started hitting, staff tried to block the AV and if s/he continued to hit, staff used an EUMR. One staff held the AV’s arms, one staff held the AV’s feet, and one staff called for help. In addition, one staff encouraged the AV to breathe and calm. Staff released the EUMR when the AV was calm and behaved “like normal.”

· SP1 said that on September 28, 2025, s/he tried multiple times to move away and redirect the AV, but the AV followed and continued his/her conduct of fighting, insulting, and hitting SP1. “[The camera footage] should show I was being hit continuously by [the AV].” SP1 did not remember pushing the AV. At this point SP1 ended his/her interview with the DHS investigator.

· SP2 said that on September 28, 2025, the AV repeatedly tried to hit SP1 and SP1 repeatedly tried to move away. Staff told the AV to stop hitting and at least once, SP2 stepped between the AV and SP1. At one point, the AV kicked SP1 and started walking away, but since the AV had already kicked and punched SP1 more than once, SP1 said, “Let’s put [the AV] in a hold.” SP1 then grabbed the AV’s arms and SP2 helped by holding the AV’s legs while SP3 called 9-1-1. SP2 heard SP1 and SP3 tell the AV, “Shut up,” which SP2 believed was “not professional.”

· SP2 said that his/her back was turned during most points of the EUMR and so did not see what was happening. SP2 heard the AV state that s/he was in pain and heard SP1 or SP3 tell the AV that once s/he was calm, they would release him/her. “After a little bit,” SP1 or SP3 said that the AV appeared calm and so they all released the AV. Afterward, no one talked or attempted to debrief with the AV, which SP3 should have been doing. SP2 did not talk to or attempt to debrief with the AV because SP2 was “tired” from the EUMR.

· SP2 said that at some point after, SP1 said, “Let’s put [the AV] in a hold (second EUMR).” SP2 did not know why the second EUMR was initiated but said that the AV was still going after or attempting to hit SP1. SP1 appeared “over it” and wanted the AV to stop hitting. SP2 helped but “didn’t know exactly what was happening.” SP2 again held onto the AV’s legs and again had his/her back turned to the AV, SP1, and SP3. The second EUMR was “short.” The AV appeared calm and SP1 stated that s/he was “tired” and “couldn’t hold the AV anymore” and so they released the AV.

The FM, the G, and the CM provided the following information:

· The AV had a history of becoming dysregulated which might lead to aggression and impulsiveness. The facility provided 3:1 staffing for the AV and staff should give the AV choices, keep the AV engaged, and

avoid saying, “No.” The FM, the G, and the CM had no concerns with the facility’s overall care and supervision.

· The CM and the G each said that the AV did not typically require physical interventions (EUMRs).

The facility’s handle with care (EUMR) policies and procedures stated the following:

· Staff should attempt to deescalate a person’s behavior before it posed an imminent risk of physical harm to self or others.

· If de-escalation strategies were ineffective, an EUMR might be necessary, and to use an EUMR, the following conditions must be met:

1. An immediate intervention must be needed to protect the person or others from an imminent risk of physical harm.

2. The type of manual restraint used must be the least restrictive intervention to eliminate the imminent risk of harm and effectively achieve safety.

3. The manual restraint must end when the threat of harm ends.

· The facility allowed certain EUMR techniques, including a 1- and 2-arm standing or sitting restraint. The staff person stood behind the person, crossed the person’s arms in front of the person’s torso, and held above the person’s wrists. Staff then verbally notified the person of their intent to move to a sitting position. The staff slowly backed up and lowered the person to the floor. If the person attempted to hit staff with their head or aggressively rock back and forth, staff might pull slightly back while maintaining their restraint or brace their shoulder against the person’s shoulder or duck their head to avoid being hit.

· Staff were prohibited from pushing the person or hyperextending or twisting the person’s body parts.

Facility documentation stated that SP1-SP3 and P1 received training on the AV’s support plans, including Individual Abuse Prevention Plan; and that SP1-SP3 and P1-P2 received training on the facility’s handle with care policies and procedures and on the Reporting of Maltreatment of Minors Act.

Relevant Minnesota Statutes and Rules:

Minnesota Statutes section 245D.04, subdivision 3:

· paragraph (a), clauses (4) and (6), states, in relevant part, that a person's protection-related rights include the right to be free from restraint, as identified in sections 245D.06, subdivisions 5 and 8, and 245D.061; and the right to be treated with courtesy and respect.

· paragraph (b), clause (1), states, in relevant part, that a person's protection-related rights include the right to have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person.

Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance

with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071.

Minnesota Rules, part 9544.0060, subpart 2, states, in list form, the actions or procedures prohibited from being used as a substitute for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience, including:

· item H. hyperextending or twisting a person's body parts

· item X. manual restraint, except in an emergency in accordance with Minnesota Statutes, section 245D.061

Conclusion:

A. Maltreatment:

Camera footage showed that on September 28, 2025, SP1-SP3 initiated two emergency uses of manual restraint (EUMR) on the AV.

Regarding neglect:

Camera footage showed SP1-SP3 declining to allow the AV’s access to the phone and SP3 telling the AV that s/he lost the privilege to use the phone, which were violations of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clause (1). In addition, SP1-SP3 made limited attempts to work with the AV; ensure the AV felt heard and supported; and/or encourage the AV to leave an unsafe situation, which was inconsistent with the AV’s support plans and a violation of Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a).

SP1 then pushed the AV and initiated two EUMRs when the AV was walking away and/or there was not any apparent imminent risk of harm. SP2 and SP3 also participated in the EUMRs when, at points, the AV called out in pain, but there was no attempt to reposition or minimize the AV’s pain. By the time SP1-SP3 released each EUMR, the AV had been sitting motionless for some time and any concerns for threats of harm had long since ended but no attempts were made to release the AV sooner. SP1-SP3 then did not debrief or talk to the AV throughout the incidents but instead repeatedly laughed and talked in a language other than English, which the AV did not understand. When the AV started striking his/her head on a wall, SP1-SP3 stood by and did nothing. Although the AV did not sustain injuries, SP1’s, SP2’s, and SP3’s conduct was inconsistent with the facility’s handle with care policies and procedures and violations of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clauses (4) and (6), and Minnesota Rules, part 9544.0060, subpart 2, item X. Given the aforementioned, there was a preponderance of the evidence that there was a failure supply the AV with necessary care and a failure to protect the AV from conditions or actions that seriously endangered the AV's physical or mental health.

It was determined that neglect occurred (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).

Regarding physical abuse:

Camera footage showed that the implementation of the EUMRs by SP1-SP3 on September 28, 2025, were implemented when the AV nor others were at an imminent risk of harm and included kneeling on the AV’s hands and hyperextending the AV’s arms, which were inconsistent with the facility’s handle with care policies, inconsistent with the standards of services licensed by the Department of Human Services, and violations of Minnesota Rules, part 9544.0060, subpart 2, item H. In addition, the AV more than once called out expressing pain and stating, “You’re hurting me,” yet there were no obvious attempts to change or lessen the AV’s pain according to the camera footage. Although the AV did not sustain an injury, there was a preponderance of the evidence that the implementation of the EUMRs on September 28, 2025, was not an accident, threatened injury to the AV, and represented a substantial risk of physical 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.

SP1-SP3 each received training on the AV’s support plans, including Individual Abuse Prevention Plan; the facility’s handle with care policies and procedures; and the Reporting of Maltreatment of Minors Act.

Regarding neglect:

SP1-SP3 were each responsible for the AV’s care and supervision on September 28, 2025, and each had opportunities to intervene and/or ensure the implementation of the EUMRs was consistent with training, but they did not.

SP1-SP3 were each responsible for maltreatment by neglect of the AV. Regarding physical abuse:

Camera footage showed SP1 hyperextending and twisting the AV’s back as SP1 tried to reposition the AV, and pressing SP1’s head into the base of the AV’s head and neck to stop the AV from headbutting. Given that SP1’s actions were in response to the AV’s conduct (e.g., grabbing at SP1, headbutting) or to reposition SP1 and/or the AV, it was not determined if SP1’s actions caused or could reasonably be expected to cause threatened or substantial injury to the AV other than by accidental means. SP1’s responsibility for maltreatment by physical abuse was mitigated.

Camera footage showed SP2’s conduct as having no apparent or obvious interactions that might reasonably be expected to threaten or cause injury to the AV. SP2’s responsibility for maltreatment by physical abuse was mitigated.

Camera footage showed SP3 kneeling on the AV’s hands and hyperextending the AV’s arms while SP1 was already securely holding the AV’s arms. SP3’s conduct was not accidental or in response to an imminent risk of harm and not the least restrictive intervention necessary to achieve safety. Instead, SP3’s conduct threatened injury to the AV and represented a substantial risk of physical injury to the AV.

SP3 was responsible for maltreatment by physical abuse of the AV.

C. Recurring and/or Serious Maltreatment:

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

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

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

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

"Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application

of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult.

It was determined that the substantiated neglect for which SP1 and SP2 were responsible was considered a single incident that did not meet the definition of serious maltreatment.

It was determined that the substantiated neglect and physical abuse for which SP3 was responsible was considered a single incident that met two definitions of maltreatment and did not meet the definition of serious maltreatment.

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

Action Taken by Facility:

The facility completed an internal review and determined that policies and procedures were adequate but not followed by SP1, SP2, and SP2. “Staff implemented improper use of [emergency use of manual restraint]. Staff left the site phone out in the open and [the AV] was able to get a hold of it.” The facility provided additional training to all staff on the emergency use of manual restraints. SP1, SP2, and SP3 no longer worked at the facility.

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

SP1, SP2, and SP3 were not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP1-SP3 were each 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 disqualification. The determination that SP1-SP3 were each responsible for maltreatment is subject to appeal.

On February 19, 2026, the facility was issued a Correction Order for the violations outlined in this report.

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.


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