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MALTREATMENT INVESTIGATION MEMORANDUM 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.”
License Number and Program Type: 831080-CRF (Children’s Residential Facility) Investigator(s): Brittany Dolen 651-431-6701 Suspected Maltreatment Reported: It was reported that a staff person (SP) threw an alleged victim (AV) into a wall and that the AV hit his/her head which caused an injury. Date of Incident(s): December 18, 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 January 5, 2025; from documentation at the facility and through eight interviews conducted with the AV, the AV’s guardian (FM), the AV’s case manager (CM), two facility supervisory staff persons (P1 and P2), two facility staff persons (P3 and P4), and the SP. The AV was thirteen years old and was diagnosed with attention-deficit/hyperactivity disorder (ADHD), major depressive disorder, disruptive mood dysregulation disorder, and generalized anxiety disorder. The AV was referred to the facility due to “significant” safety concerns resulting from “impulsive and high-risk unsafe behaviors” such as fire setting, engaging in unlawful activities, and eloping from home. The AV had a history of suicidal ideation and self-injurious behaviors, inconsistent reporting, manipulation, and thoughts of harm towards him/herself and others. The AV enjoyed helping others, sports, music, and “handyman” tasks. The AV’s Residential Treatment Plan said staff persons worked with the AV on developing skills to “support stress management and impulsivity” and used “time outs” when the AV needed space to deescalate. If necessary, staff persons used “handle with care” restraint as a physical intervention with the AV, only if the AV was “unable to redirect and continued to escalate, posing imminent safety risk to self or others.” The AV’s Individual Guidance Plan said that the AV “shut down” when s/he was upset, and staff persons spoke to the AV “calmly and respectfully” and gave the AV space if s/he asked. The AV became upset when staff persons yelled or used a “harsh” tone, did not listen to and/or ignored the AV, and blamed the AV without asking him/her what happened. The AV thought that taking a walk, listening to music, deep breathing, and talking to someone s/he trusted were ways to help him/her calm. The AV’s Approval Use of Restrictive Procedures said the AV was “at risk” of patterns of unsafe behavior, had not learned “limits and personal responsibility,” and required time-outs when s/he engaged in manipulative or disruptive behavior. Staff persons were trained and approved to complete physical holds on the AV if s/he was aggressive towards him/herself or others, and/or expressed thoughts of suicidal ideation. The facilities Handle with Care (HWC) therapeutic restrictive procedures policy provided the following information: · Staff persons were given a copy of the procedure during staff person orientation and completed an HWC course before approved to implement the emergency use of restrictive procedures. · HWC was implemented only by trained staff persons, and only if the AV presented physical aggression that put him/herself or others at risk of “imminent danger” and to prevent “self-harm/self-destructive behaviors” that put the AV or others in imminent danger. · When staff persons completed the approved physical holds, the type of hold utilized was always the “least restrictive holding necessary for maintaining safety.” · Two staff persons were involved in the physical hold process to provide “a check and balance.” · A supervisory staff person or clinical supervisor on duty would be informed of the potential need for a physical hold. · Staff persons not involved in the hold witnessed and monitored for any maneuvers that could cause possible injury. · Arm twisting, arms held high behind the back, hair pulling, and excessive squeezing were not acceptable or tolerated and the hold was terminated as soon as the threat of harm to self or others subsided. The AV provided the following information: · On the date of the incident, the SP stood by the AV’s doorway and the AV told the SP, “Don’t stand by my doorway,” because it was going to make the AV “mad.” The SP told the AV that s/he was told to stand by the AV’s door. · The AV “flicked [the SP] off” and the SP tried to grab the AV’s hand. The SP told the AV that s/he was in the SP’s “personal bubble”, but the AV thought s/he was three feet away from the SP. The AV punched his/her pillow on the wall in his/her bedroom and then punched the pillow “up” close to the SP. The SP “grabbed” the AV’s arm and “threw” the AV to the ground. The AV then “got in [the SP’s] face and “flicked” the SP off. The SP tried to grab the AV’s hand again, and the AV told the SP to get out of his/her doorway. · The SP did not leave the doorway, so the AV went “into [the SP’s] face” and flicked the SP off again. The SP “pushed” the AV, flicked the AV off, and then “threw” the AV into his/her bedroom. The SP then entered the AV’s bedroom without another staff person present, “picked [the AV] up” and “slammed” the AV into the wall. The AV hit his/her head on the windowsill. · When the SP threw the AV, the SP picked the AV up under the AV’s armpits and used his/her thumbs to “dig” into the AV’s armpit. When the AV hit his/her head on the windowsill, the AV’s eyes “blacked out” and the SP left the AV’s bedroom. The AV then got up, punched the SP in the back, and kicked the SP. The AV saw P4 in the hallway but did not know if P4 saw the SP throw the AV. The SP left the AV’s bedroom. · The AV’s head was “throbbing” and P4 felt the AV’s head and found a “huge lump” on the back of the AV’s head. P4 told the AV to lie down, and the AV fell asleep. The AV had pain in his/her head for “maybe four days” and “pus” came out of his/her head. The AV denied s/he told any staff person about the pus. · The day after the incident, the AV told P1 and P2 what happened, and the SP was “fired.” · The AV and the SP did not get along, and the AV thought the SP was a “jerk” and “made stuff up” about the AV not being safe so the SP could put the AV in a hold. · Staff persons were not allowed to enter residents’ bedrooms without a second staff person present to make sure nothing “inappropriate” happened. The AV was placed in holds prior to the incident, and there needed to be two staff persons present when a hold was completed. P4 provided the following information: · On the date of the incident, around 8:25 p.m., P4 worked at the facility with P3 and the SP. P3 was in the medication room at the time of the incident, and as P4 walked in the hallway of the facility, s/he heard the AV and the SP yell at each other. P4 did not hear everything the AV and the SP said, but heard the SP say, “get out of my bubble” and “quit kicking me.” · When P4 approached the AV’s bedroom, s/he saw the AV “flick off” the SP. P4 heard the SP say, “stop doing that” and “get out of my face” so P4 watched from the hallway to see what happened. P4 turned away “for a second” and when s/he turned back, P4 saw the SP “grab” the AV by the arms and “throw” the AV against the wall. The AV got up and the SP grabbed the AV by the arms again and “threw” the AV against the windowsill. P4 heard a loud “smack” and the AV “cried out” because the AV hit his/her head. P3 then came out of the medication room and got the SP out of the AV’s bedroom. · P3 looked at the AV’s head and asked P4 to look as well. When P4 did so, s/he felt a “giant goose egg” on the back of the AV’s head. After the incident occurred, P4 notified the G, completed an incident report, and sat with the AV who “cried” and was “balled up.” The AV said s/he was “mad and hurt” and thanked P4 for sitting with him/her. · P4 did not know what happened before the incident, but said the SP was “upset” with every resident that night and “engaged” with them. More than once P3 and P4 told the SP to stop arguing with the residents, and P4 thought the SP “set [the AV] off” because P4 told the SP to step away from the AV’s bedroom door, but the SP did not listen to P4. · Staff persons were trained on certain protocols and holds if residents were physical but were trained to not engage with residents during verbal altercations, and to “ignore” or “walk away” from the situation. Grabbing a resident by the arms and throwing them was not an approved physical intervention. P3 provided the following information: · On the date of the incident, around 8:35-8:40 p.m., there was an incident between the SP and the AV. At the time of the incident, it was bedtime, and the AV was supposed to be in his/her bedroom. The AV said s/he was “anxious” and requested his/her pro re nata (PRN) medication, so P3 went to the medication room to retrieve it. The medication room was “around the corner” from the AV’s bedroom and P3 could not see the bedroom, but “heard a commotion” so s/he walked around the corner and down the hallway to see what happened. · When P3 got to the AV’s bedroom, the AV was “screaming and crying” and “holding [his/her] head.” The SP stood in the AV’s doorway and P4 was walking towards P3. P3 asked the SP to move and asked the AV what happened. The AV told P3 that the SP “picked up and tossed” the AV, and the AV hit his/her head on the windowsill. The SP denied s/he threw the AV and was “in [P3’s] ear” saying the AV tried to kick the SP and “flicked” the SP off. · P3 separated the AV and the SP, stood in the AV’s doorway and asked the AV to “come to” P3, within camera view. P3 then asked the AV where his/her head hurt. The AV showed P3 a “goose egg” about an inch in size on the back left side of the AV’s head. The AV said it hurt “to the touch” and P3 denied there was broken skin or bleeding. P3 then offered the AV medication and ice and completed a concussion protocol. · When the AV settled, P3 called a staff person from a different part of the facility to “swap” with the SP and called P2 to tell him/her what happened. P3 then asked P4 what happened, but P4 did not give P3 any detail and said, “I can’t believe [the SP] would do that.” P3 did not speak with the SP. · The facility had cameras in the hallway, but not in residents’ bedrooms. P3 did not know if video from the incident was reviewed and said that staff persons were not allowed to enter a resident’s bedroom without another staff person present as a witness. · Prior to this incident, the AV required physical holds “two to three” times per week due to physical aggression towards staff persons, being a danger to him/herself, climbing on furniture, hanging from the ceiling, and attempting to elope from the facility. · Staff persons received two weeks of employee orientation which included de-escalation techniques and the HWC protocol if residents became aggressive. Staff persons were permitted to be “hands on” if residents became physical or were a danger to themselves or others, but first, staff persons should de-escalate by “stepping away” and “creating space” between themselves and the resident. P1 and P2 provided the following consistent information: · On December 18, 2025, at an unknown time, P3 called P2 and told him/her that the AV told P3 the SP “threw” the AV in his/her bedroom and the AV hit his/her head. P3 told P2 that the SP and another staff person switched units and P3 was “looking for direction” on what to do next. P2 advised P3 to monitor the AV for a concussion to determine whether the AV needed medical attention. After monitoring the AV, it was determined s/he did not need medical attention. · On December 19, 2025, around 8 a.m., P2 met with P1 and told P1 what s/he knew about the incident, and it was determined that P2 would ask P3, P4, and the SP to complete written statements regarding the incident. · P1 and P2 then spoke with the AV and asked him/her what happened. The AV was “difficult to follow” but said s/he was “flipping off” the SP, and things proceeded from there. P2 thought the AV said s/he told the SP to “fuck off” or “get away” but did not know for sure. The AV changed some details of his/her story but was consistent that the SP picked the AV up under the arms and “pushed or threw” the AV, and the AV hit his/her head on the windowsill. P1 asked the AV what happened prior to the incident, but the AV “very much tried to walk around that.” · On or around December 22, 2025, P1 spoke with the SP who told P1 that on the day the incident occurred, the SP thought the AV was going to punch him/her, and the SP thought that “gave [the SP] the right” to enter the AV’s bedroom. The AV “got in [the SP’s] face” and then “pulled” the SP into the AV’s bedroom and pulled the SP down on top of the AV, which was when the AV hit his/her head. The SP also said the AV kicked the SP during the incident but when P1 spoke with P4, P4 told P1 that s/he did not see the AV kick the SP. · P2 reviewed the SP’s, P3’s, and P4’s witness statements, and did not find information to indicate that the AV put him/herself or anyone else in danger prior to the incident and in his/her witness statement. The SP admitted that s/he pushed the AV away from the SP prior to the incident occurring, because the AV attempted to “put [his/her] hands” on the SP. · The AV had a history of physical aggression and was sometimes placed in holds on a daily basis. The AV was placed in holds when s/he tried to elope and when s/he became aggressive with other residents and staff persons. · Staff persons were trained on appropriate physical restraints of residents and utilized HWC. Physical restraints under HWC were generally a staff person standing behind a resident, with their arms “intertwined” in the residents’ arms. Staff persons would then be able to escort the resident away from a situation safely. If necessary, staff persons completed seated holds or had a second staff assist a resident to the floor on their back, with staff persons holding the residents’ arms out to prevent aggression. · The AV had issues with most staff persons and “did not do great” when staff persons held a limit with him/her. P2 thought the AV and the SP had previous issues, but nothing “extreme.” The AV showed the SP “higher levels” of defiance, and attempted to get aggressive with the SP. · P2 thought there was sometimes concern with the SP’s tone of voice with residents but did not have previous concern with the SP when s/he worked at the facility. The SP provided the following information: · On December 18th, 2025, the AV had behaviors before bedtime so P3 asked the SP to “hang out” by the AV’s bedroom door while P3 got the AV’s medication. The SP shut one door in the hallway to the resident bedrooms because the AV was “notorious for running off dorm” and stood at the hallway door, but P3 told the SP to move to the AV’s doorway. The SP then stood in the hallway outside of the AV’s door frame and “kept [him/herself] in camera view.” · While the SP stood by the AV’s door, the AV tried to push past the SP “a few times” and the SP told the AV to “chill.” The AV then “paced all over” in his/her bedroom and came back to the doorway and tried to “push through” the SP to get out. The SP thought the AV asked him/her not to stand in the AV’s doorway, and the SP told the AV s/he needed to stand there until P3 returned with the AV’s meds. · When the AV came towards the SP, the SP used one palm to “push [the AV] back” from the SP. The AV did not show aggression, so the SP tried to “create distance” between him/herself and the AV. The SP told the AV “Multiple” times to “stay out of [his/her] bubble” but the AV continued to come towards the SP. · The AV then “took a full swing” towards the SP, so the SP initiated a hold and “grabbed” the AV’s right arm. The AV then rotated his/her body and “plopped down” on his/her bed, and when the AV rotated his/her body, the SP let go of the AV’s arm because there was no longer aggression towards the SP. The AV “grabbed” the SP’s hoodie sleeves and “pulled forward.” When the AV pulled forward, the AV’s foot hit the SP’s ankle and the SP “fell onto” the AV. When the SP fell onto the AV, the AV hit his/her head on the wall behind his/her bed. The SP left the room as soon as the AV let go of his/her sleeves. · When the SP left AV’s bedroom, P4 was in the area of the doorway and told the SP s/he was going to get P3. When P3 got to the AV’s bedroom, the AV told P3 that the SP “picked [the AV] up and threw [the AV] into the wall,” and that the back of his/her head hurt. The SP then took a break and worked the remainder of his/her shift in a different area of the facility. · On December 19, 2025, the SP received a text message from P1 asking that the SP come to the facility before his/her shift began. The SP did so, and met with P1 and P2, who told the SP there were “witness statements” from two staff persons, and that the SP was suspended. The SP asked how there were two witness statements when only P4 was present for the incident and did not receive an answer. · Staff persons could not enter a resident’s bedroom unless there was another staff present. When the SP first entered the AV’s bedroom, P4 was standing next to the SP, but when the SP entered the AV’s bedroom, P4 walked up the hallway which “confused” the SP. · Staff persons were trained in HWC to conduct physical holds on residents if necessary. The SP thought staff persons could initiate a physical hold if residents physically hit a staff person, and they had initiated “several” holds on the AV for aggression towards staff members and other residents, attempting self-harm and attempting to elope from the facility. · The SP denied s/he threw the SP into the wall or window in the AV’s bedroom. The facility provided video footage from December 18, 2025, which was time stamped but did not contain audio. The video provided the following information (note: the video was missing over a minute of footage during the time the incident occurred, and attempts to obtain the full video were unsuccessful): · At 8:29:49 p.m., the SP stood at the hallway door. The door to the right was closed, and the SP stood in front of the open left door. Another unidentified staff person, believed to be P4, was seen moving on the opposite end of the hallway from the SP. · At 8:30:27 p.m., the SP walked towards the AV’s bedroom door and stood outside of the door in the hallway, with his/her hands in his/her pockets. · At 8:30:39 p.m., the AV looked out of his/her bedroom door to the left. The SP stood in the same spot outside of the doorway. The video glitched until 8:30:50 p.m., at which time the AV stepped out of his/her bedroom wrapped in a blanket and the SP used two hands to guide the AV back into his/her bedroom. · At 8:30:59 p.m., the AV looked out of his/her bedroom door and the video glitched until 8:32:10 p.m., at which time the video showed the SP leaned forward into the AV’s bedroom with his/her lower torso and legs outside of the AV’s bedroom until 8:32:13 when the AV’s bedroom light turned on and the SP leaned backwards and remained in the doorframe. · At 8:32:20 p.m., the unidentified staff person (likely P4) slowly walked towards the AV’s bedroom and arrived at the AV’s doorway at 8:32:27 p.m. Both the SP and P4 stood in the AV’s doorway, in view of the camera until 8:33:01 p.m., and the recording ended. Neither the SP nor P4 appeared in distress. The FM was aware of the allegation and did not have previous concern with the facility. The AV had “a tendency to not tell the whole story, “Often identified him/herself as the “victim” in every situation, and found any opportunity to “be in a new place and start over.” The G “loved” the facility and thought they were doing a “great job” with the AV. The CM was aware of the allegation and did not have previous concern with the facility. Personnel files showed that P1-P4 and the SP were all trained on the AV’s plans, facility policies and procedures, and the reporting Maltreatment of Minors Act.
Relevant Rules and/or Statutes: Minnesota Rules Part 2960.0050, subpart 1, item R states that a resident has a right to be free from restraint or seclusions used for a purpose other than to protect the resident from imminent danger to self or others. Conclusion: A. Maltreatment: The AV had a history of being physically aggressive, and staff persons were trained to redirect the AV, but were permitted to complete physical holds if the AV was a danger to him/herself and/or others. The facility’s HWC Policy required two staff persons to be present if a physical hold was implemented to provide a “check and balance” and the AV’s plans said when the AV was upset, staff persons should give the AV space to deescalate. On December 18, 2025, the AV was upset so the SP stood in the hallway near the AV’s doorway to ensure the AV remained in his/her bedroom. The AV said that the SP entered the AV’s bedroom and “picked [the AV] up” under his/her arms and “slammed” the AV into the wall, and the AV hit his/her head on the windowsill. P4 said s/he saw the AV hit his/her head on the windowsill in his/her bedroom after the SP “threw” the AV into the wall. The SP said that while the SP stood in the AV’s doorway, the AV came towards the SP, and the SP used one palm to “push [the AV] back.” The AV “took a full swing” towards the SP, so the SP attempted to place the AV in a physical hold. The AV grabbed the SP’s shirt and pulled the SP into the AV’s bedroom, which caused the SP to fall onto the AV and the AV to fall back and strike his/her head on the wall which caused a bump on the AV’s head that did not require medical attention. The SP denied throwing the AV into a wall and or/windowsill. Video footage provided by the facility did not show P4 near the AV’s bedroom when the incident occurred, did not show the SP fully entering the AV’s bedroom, or show any physical indication of the SP picking up and throwing the AV and or falling on top of the AV. Although the video did not show the SP entering the AV’s bedroom, there was just over a one-minute glitch in the video, and it was likely this was when the SP entered the AV’s bedroom as the SP said s/he entered the AV’s bedroom and attempted to place the AV in a hold. The SP attempted the hold alone, which required two staff persons per facility policy, and P1 and P2 said after a review of the incident that the AV did not appear to present a risk to him/herself or others at the time of the incident, which was a violation of Minnesota Rules Part 2960.0050, subpart 1, item R. Regarding physical abuse: Although the AV and P4 said that the SP “threw” the AV into the wall given that video footage did not show the that P4 was near the AV’s bedroom during the incident and only arrived to the AV’s bedroom door after the glitch in the video when the SP stood outside the door, that the SP said s/he was attempting to implement a physical hold when the AV hit his/her head, and that the SP denied throwing the AV, there was not a preponderance of the evidence whether the AV’s injury was caused any means other than accidental. It was not determined whether physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Regarding neglect: Given that the SP did not follow the facility’s policies and/or the AV’s plans including that during all holds two staff persons were present, that staff persons were not to be in client bedrooms, and that the SP did not allow the AV space to deescalate which resulted in an injury to the AV, and that the AV did not appear to present a risk to him/herself or others at the time of the incident, there was a preponderance of the evidence that there was a failure to protect the AV from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so and/or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on facility policies and procedures, the AV’s plans and the Reporting Maltreatment of Minors Act. At the time of the incident, the SP was responsible for providing necessary cares to the AV to ensure the AV’s health, safety and wellbeing. The SP was responsible for maltreatment of the AV. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious because it was a single incident and the AV did not require medical attention. 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. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal. On August 20, 2026, the facility was issued a Correction Order for the violation 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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