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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: 1044451-CCC (Child Care Center) Investigator(s): Danielle Morrison 651-431-5647 Suspected Maltreatment Reported: It was reported that a staff person (SP) kicked, pushed, and physically restrained alleged victims (AV1-AV10). Date of Incident(s): Ongoing prior to September 15, 2023 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 September 22 and 25, 2023; from documentation at the facility; and through 20 interviews conducted with seven facility staff persons (the SP and P1-P6), two supervisory staff persons (P7 and P8), AV1’s family members (FM1 and FM11), and AV2’s-AV10’s family members respectively (FM2, FM3, FM4, FM5, FM6, FM7, FM8, FM9, and FM10). This investigator met with AV2 and AV6-AV10 and none provided details pertaining to this investigation. This investigator did not meet with AV1, and AV3-AV5 because of their respective ages and/or not being at the facility during the site visits. AV1-AV10 ranged in ages from 25-47 months and attended classrooms at the facility based on their age. The facility had 11 classrooms. The Pathways I classroom was across the hallway from an office and the Pathways II classroom was adjacent to that and those two classrooms were a pod for that age group. Staff persons worked between the two classrooms. P1 provided the following information: · Sometime in May 2023, the SP sat AV1 in his/her lap and physically restrained AV1 because AV1 did not listen to the SP. P1 said that the SP put one leg over AV1 restraining his/her movement and called it the “seatbelt.” AV1 responded by screaming, crying, and telling the SP, “Stop.” P1 saw this happen six times in one day. The SP told other staff persons to do this as well, but P1 stated that no other staff person did that. · During one of the times the SP had AV1 restrained, AV6 was near them and the SP pushed AV6’s head into the floor and asked him/her if s/he liked that. · Sometime in the beginning of June 2023, the SP told staff persons in the pod to “girl fight” and slap at AV3’s hands when AV3 followed and clung to a staff person. (Note: P1 had his/her hands in front of him/her and made up and down motion with his/her hands to show what this meant.) · P1 saw the SP “jokingly” shoved AV4 to the floor. Sometime in June 2023 or July 2023, AV2 got up and ran so the SP grabbed his/her head turned it and “forcefully” pushed AV2 causing him/her to fall to the floor on his/her knee. P1 said AV2 had a scraped knee “like a rugburn,” but it did not break his/her skin and had a “rash look.” The SP said staff persons did not have to write an incident report for it because it did not break the skin. · On an unknown date in the beginning of August 2023, AV8 was in a frog squatted position and the SP was seated in a teacher chair. The SP pushed AV8 over with his/her foot and made a comment about, “Some people would say I am abusing a child.” · The first week of September 2023, AV7 was in the SP’s way so the SP used his/her foot to get AV7 out of the way. P1 said the SP “trie[d] to make it a play kick” but there was some force to it and AV7 started to cry. · On an unknown date AV9 was playing with another child in a learning center area and AV9 took a piece of play bread from the other child. The SP went over to AV9 and stated to AV9, “You do not like it when I do that to you.” The SP then took the bread back from AV9 and pushed AV9 to the floor causing him/her to cry “uncontrollably” so that s/he was not able to catch his/her breath. · P1 said that if a child was not sitting on the carpet the SP gave them a countdown and then would physically move the child and set them down in a way that the child “almost bounced off the ground.” · P1 said s/he was not sure how s/he was trained on behavior guidance, P1 took his/her knowledge from previous positions. P1 had a meeting with P7 on September 7, 2023, to express concerns about how the SP treated children. P7 told P1 s/he and/or P8 would do classroom observations. P1 stated no observations had been done in the classroom. P1 stated that the SP had a “very close relationship” with P7 and P8 and P8 “backed” the SP up in situations before. P3 provided the following information: · When AV1 did not want to listen (not sitting nicely, walking around when s/he was supposed to be sitting, or rolling around on the carpet), the SP held AV1 in his/her lap and restrained him/her. AV1 was “upset” and s/he “thrashed around” and told the SP, “I don’t want to sit like this.” P3 stated that the SP held AV1 like this for 60-90 seconds. · The SP used threats toward the children such as not being able to have a snack or asking a child if the SP needed to kick that child to show it was not okay to kick another child. P3 did not see the SP “kick” a child, but P3 did see the SP use his/her foot on a child’s legs or feet when sitting on carpet shapes if the SP wanted a child to keep his/her feet to him/herself. · P3 witnessed the SP “shove” or “push” a child to get out of the way or if that child was doing something to another child to get the child out of the area s/he was previously in. P3 stated the child would either cry because s/he got moved or would “shut down” because the child did not realize why s/he got moved. P3 stated that the SP was “quick” and “more aggressive” when the SP was having an “off day.” P3 remembered AV1 and AV8 falling to the floor when the SP “pushed” them. P3 did not think AV1 and AV8 sustained any injuries due to the fall. · P3 said that when the SP was “frustrated” s/he was more “aggressive” and moved a child quickly and plopped him/her down “very sudden[ly].” P3 said the SP’s tone of voice was “pretty cold” and “stern” almost like the SP was “fed up with the child.” P3 recalled it mostly being AV1 and AV8 that the SP treated this way. · P3 was trained to be gentle and encouraging towards the children for behavior guidance. P3 said there was “favoritism” towards the SP from P7 and P8 and the SP had a “good relationship” with them. P3 wondered if s/he was “at risk” from the facility for retaliation. P2 provided the following information: · P2 said that if AV3 was “upset” and hit a staff person, the SP went to AV3 and “hit [him/her] back” and asked the AV if s/he “liked that.” The SP also took AV3’s hands and moved them around until AV3 was crying and “cowering.” · When AV1 was walking around and not listening during circle time, P2 saw the SP restrain AV1 by putting his/her leg on AV1. AV1 cried and screamed, “Ow.” The SP told AV1 that s/he needed to sit on his/her shape in the circle if s/he did not want “this.” P2 said it was about six to eight times over a week that this happened, and the longest duration was five to six minutes. The SP called it the “seatbelt” and after that week the SP threatened AV1 with “the seatbelt” when AV1 was not listening. · On an unknown date, AV2 kicked another child and the SP kicked AV2 (P2 did not say where) and said, “Did you like that? No, then don’t do that again.” P2 stated that AV2 cried when that happened. · On an unknown date, AV5 was seated and kicked a child, so the SP got up out of a chair and went over to AV5 and used his/her foot to move AV5 across the carpet while asking AV5, “Did you like that? We do not kick friends.” · On an unknown date, AV9 took a toy from another child and the SP went over and “ripped” the toy out of AV9’s hands and “shoved” AV9 with his/her forearm, causing AV9 to fall over and start crying. P2 stated that when a child started crying, the SP walked away and one of the other staff persons went and comforted the child. · P2 was trained that staff persons do not say, “No,” to the children. P2 stated that s/he “feared” retaliation because the SP had a “close” relationship with P8. On an unknown date in September 2023, P4 was having a conversation with P8 on the playground when P4 saw the SP “grab” and “shove” AV10 when AV10 scratched another child. P4 said the SP should have gently removed AV10 and the other child from the situation. P4 was not sure if P8 saw this so P4 called out to the SP that “pushing” AV10 was not okay. P4 told P8 that the SP pushed AV10 and P8 told P4 that s/he “was going to handle [it].” P4 said the other child was crying so the SP comforted them and AV10 ran away. P4 went over and talked with AV10 who was also crying. P4 did not hear anything more from P8 about the situation. P4 thought s/he and P8 were about 15 feet away from where this occurred. On an unknown date in September 2023, P5 was outside and saw AV10 scratch another child and the SP “yanked” AV10 away. AV10 started crying immediately. P5 said AV10 did not fall to the floor. P5 said P4 was the closest to what happened so P4 went over to console AV10. P5 stated in the past a staff person had brought concerns about comments the SP had made about children to P8 and P8 told the SP what was said and that was why staff persons had not come forward as there was “no confidentiality.” If a child was hurting another child or not “calming” their body, P6 saw the SP put them in a “hold.” The SP sat behind the child and crossed his/her leg over the child’s leg. P6 did not know the names of the children s/he saw the SP do this to. P6 said it lasted about 30 seconds each time. The SP told P6 s/he called it the “seatbelt” method. P6 said the children knew they were in “trouble” and would scream, thrash, and sometimes said, “Ow.” P6 said s/he would not like it if the SP did that to a child of P6’s especially if the child was saying, “Ow.” P6 said s/he was not trained by the facility to do that. P6 was told by the SP to do “silent redirection” which meant that if a child was not listening, ask the child to do the action wanted (i.e. sit on the carpet), then ask again, “Please come sit down,” and finally go and pick the child up and show them what you want them to be doing (the SP “plopped” the child down on the floor and moved the child’s feet into crisscross position). P6 said the SP was more “stern” when s/he did this. P6 said the SP was “frustrated” when children did not listen. P6 said that the SP was passionate and would “never” hurt the children. P7 said that about a week before this investigator’s site visit, s/he was brought concerns about the SP from P1. P7 said P1 did not “go into specific treatment of the [children],” that s/he was concerned about. P7 said s/he “was caught off guard” as the SP was a “really great” staff person and his/her classroom was close to the office so P7 and P8 were “tuned” to the SP’s teaching style. P7 said staff persons were trained to get to a child’s level and discuss how to change behavior and use positive redirection. P7 said staff persons were not trained to physically restrain a child and s/he had not heard of the “seatbelt” method. P7 had not seen the SP hit, kick, shove, push, or physically retrain a child. As a result of the meeting with P1, P7 said s/he and P8 conducted observations in the classroom. P7 did not document his/her observations of the classroom but did not see anything s/he was “too concerned” about. P7 had not talked with the other staff persons in the classroom at the time of this investigator’s site visit. P7 said the SP had a “good heart” and was there for the children and it was hard to hear these allegations. P7 did not feel the allegations “matched up.” P8 stated that s/he was on the playground talking with P4 and P4 said to the SP, “You cannot push [him/her] like that.” P8 stated that s/he and P4 were the length of the playground away from the SP about 60-70 feet when P4 said this. When P8 and P4 went over to the SP, s/he had his/her arm out preventing AV10 from getting close to another child AV10 had just scratched. P8 said AV10 was crying but was standing and walked away. P8 did not see the SP push AV10, only that the SP had his/her arm out. The SP said s/he had his/her arm out so AV10 gave the other child space. P8 did not witness the SP hit, kick, or physically restrain a child. P8 said staff persons were “never” trained to physically restrain a child. P8 said staff persons were trained to positively redirect children and give choices. FM1-FM11 provided the following information: · FM1 stated that AV1 was “happy” when s/he was picked up from the facility. FM11 stated that the SP and P6 seemed “more cold and standoffish.” FM11 stated that s/he witnessed a child crying at the window and staff persons “ignored” the child. Eventually a staff person comforted the child, but FM11 did not know if that was because s/he was there. · FM2 stated that the SP was a little bit “tough,” and it was more a lack of professionalism talking to family members. FM2 stated that “sometimes” s/he could tell the SP was “losing patience” with the children and that the SP was not as “friendly and outgoing” as some of the other staff persons. FM2 stated that one time at drop off, AV2 was upset, and the SP told him/her to go sit on a shape on the carpet. FM2 stated that the SP did “this thing” where s/he told a child to do something and if they did not do it the SP counted down from five, and then if the child still did not or could not do it the SP helped them. FM2 said sometimes it took time to process what staff persons were saying. · FM3 said that all staff persons that worked with AV3 have been consistent, communicative, and FM3 had no prior concerns with the staff persons in the classrooms. · FM4 said AV4 has not had concerns with the SP and FM4 stated the classrooms were welcoming, staff persons were open to communication, and there were no negative experiences. · FM5 stated his/her family has had a wonderful experience at the facility and that AV5 stated s/he liked the staff persons. · FM6 had no prior concerns about the SP. · FM7 said that AV7 seemed “happy” to be going to the facility and FM7 had no prior concerns. · FM8 stated that AV8 seemed “really happy” at the facility and had a lot of really good friends. FM8 stated that AV8 came home with “a lot of” bruises and was told that the children were playing “rough.” FM8 said that AV8 talked about the SP but there were no concerns regarding his/her care of AV8. · FM9 said AV9 “always” came home from the facility happy and FM9 had no prior concerns. · FM10 stated that s/he had no concerns and AV10 really liked his/her teachers. The SP provided the following information: · When asked by this investigator if the SP ever physically restrained a child s/he said, “No.” When asked by this investigator about the “seatbelt” method the SP described that s/he would sit behind AV1 with the SP’s legs in a “V” shape and AV1 was in between them. The SP said his/her legs might have touched AV1’s legs but s/he sat behind AV1 to help AV1 “calm down.” · The SP said this happened at the beginning of summer 2023 because AV1 was doing unsafe things during group time (examples: climbing on tables, rolling into other children on the carpet, or crawling underneath the tables). When asked by this investigator if the SP ever used his/her leg to restrain AV1 while in the position, the SP said, “Yes,” but only once or twice because then the SP remembered staff persons were not supposed to physically restrain a child. · The SP said AV1 whined when the SP restrained him/her but did not cry. AV1 tried to flail around, and the SP was trying to help AV1 “make safer choices.” AV1 did not tell the SP to, “Stop,” or say, “No.” The SP said the restraint lasted 30-60 seconds and when s/he was just sitting behind AV1 with his/her legs on either side of AV1 it lasted about two to five minutes. The SP stated s/he was “admittedly frustrated” when s/he did this because no other staff person was helping correct AV1’s behavior to make safe choices. · The SP denied kicking any child, but stated s/he had told a child if that child was kicking another child, “You are kicking [his/her] body, how would you feel if I kicked your body?” · The SP stated that if a child took a toy from another child, the SP walked over, got down to the children’s level, and took the toy to give back to the child it was taken from. The SP denied pushing or shoving any child. The SP did not recall the incident where AV10 scratched another child. · If a child hit the SP, the SP held the child’s hands away from the SP. The SP denied slapping or hitting any child. · The SP said that s/he moved children in the past if they were not listening. The SP did this by picking the child up underneath his/her armpits and bringing them to a new area. The SP said s/he set the child down, but not hard enough for them to “bounce.” The facility’s Positive Behavioral Guidance Policy stated, “The following types of discipline and guidance were prohibited: ‘Subjecting a child to corporal punishment, which includes but is not limited to rough handling, kicking, [and] hitting.’ ‘Subjecting a child to emotional distress, which includes but is not limited to language that threatens or frightens a child.’ ‘The use of physical restraint other than to physically hold a child where containment is necessary to protect a child or others from harm.’” The facility’s Parent Handbook stated, “[The facility] does not allow physical abuse, humiliation, bribery, verbal intimidation, or threatening attitudes toward children in our [facility].” Facility records showed that the SP and P1-P8 were all trained on the facility’s Positive Behavioral Guidance Policy and the Reporting of Maltreatment of Minors Act. Relevant Rule and/or Statute Minnesota Rules, part 9503.0055, subpart 1, item A, states that facilities must ensure that each child is provided with a positive model of acceptable behavior. Minnesota Rules, part 9503.0055, subpart 3, item A, prohibits the use of corporal punishment including but not limited to in part, rough handling, kicking, hitting, and spanking. Conclusion: A. Maltreatment: P1 saw the SP sit AV1 in his/her lap and physically restrain AV1 because AV1 did not listen to the SP. P1 said that the SP put one leg over AV1 restraining his/her movement and called it the “seatbelt.” AV1 responded by screaming, crying, and telling the SP, “Stop.” P2 said when AV1 was walking around and not listening during circle time, P2 saw the SP restrain AV1 by putting his/her leg on AV1. AV1 cried and screamed, “Ow.” P3 said when AV1 did not want to listen (not sitting nicely, walking around when s/he was supposed to be sitting, or rolling around on the carpet), the SP held AV1 in his/her lap and restrained him/her. AV1 was “upset” and s/he “thrashed around” and told the SP, “I don’t want to sit like this.” If a child was hurting another child or not “calming” their body, P6 saw the SP put them in a “hold.” The SP sat behind the child and crossed his/her leg over the child’s leg. P6 did not know the names of the children s/he saw the SP do this to. P6 said the children knew they were in “trouble” and would scream, thrash, and sometimes said, “Ow.” On different occasions P1, P2, and P3 saw the SP shove or push AV2, AV4, AV6, AV8, and AV9. P4 and P5 saw the SP shove AV10. P1, P2, and P3 witnessed the SP use his/her foot to “redirect children” when the children were not listening. P1 said at times the SP used more force when doing that. P1 and P2 saw the SP slap or hit AV3 when AV3 hit the SP. P3 and P6 saw the SP “plop” down a child on the floor. P6 said the SP was more “stern” when s/he did this. P1 stated that s/he saw the SP set a child down to where a child “almost bounced off the ground.” P2 saw the SP kick AV2 and AV5. P1 and P2 heard the SP ask children (AV2, AV3, AV5, and AV9) if they liked when s/he did those things to them (kicking, hitting, or pushing) after the SP saw them do those things to other children and then the SP did those things to AV2, AV3, AV5, and AV9. FM2 stated that “sometimes” s/he could tell the SP was “losing patience” with the children and that the SP was not as “friendly and outgoing” as some of the other staff persons and FM11 stated that the SP seemed “more cold and standoffish.” FM3-FM10 did not have concerns about the SP. P7 and P8 had not witnessed the SP kick, hit, slap, push, shove, or physically restrain a child. P7 and P8 stated that staff persons were not trained to physically restrain a child. The SP stated that s/he had restrained AV1 once or twice when AV1 was exhibiting unsafe behavior. The SP stated that AV1 did not say, “No,” or “Stop,” but whined when the SP did this. The SP stated s/he had told a child if that child was kicking another child, “You are kicking [his/her] body, how would you feel if I kicked your body?” The SP denied kicking, hitting, slapping, pushing, or shoving a child. P1, P2, P3, and P6 witnessed the SP put a child in a restraint to the point that the child cried out for the SP to, “Stop,” “I don’t want to sit like this,” or said, “Ow.” P1, P2, and P3 all stated that AV1 was not a danger to him/herself at the time the SP did this; P1, P2, P3, P4, and P5 witnessed the SP kick, slap, push, or shove other children on various occasions; these actions were inconsistent with the facility’s Positive Behavioral Guidance Policy; and were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and violations of Minnesota Rules, part 9503.0055, subpart 1, item A; and subpart 3, item A. The SP denied the allegations however, the SP had reason to minimize his/her actions and several staff persons observed the SP’s actions with different children and different incidents. It was reasonable that not all staff persons each saw all the incidents but P1, P2, P3, P4, and P5 each provided information similar in nature regarding the SP’s actions and incidents they observed. Therefore, P1’s, P2’s, P3’s, P4’s, and P5’s information was considered more credible that the SP’s. Given that several staff persons stated that the SP kicked, slapped, pushed, or shoved children on various occasions, there was a preponderance of the evidence that the SP’s actions represented a pattern of threatened injury to children in his/her care. 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). In addition, there was a preponderance of the evidence that the SP’s actions represented a failure to supply AV1-AV10 with reasonable and necessary care and a failure to protect AV1-AV10 from conditions or actions that seriously endangered AV1’s-AV10’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. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the facility’s Positive Behavioral Guidance Policy and the Reporting of Maltreatment of Minors Act. The SP was responsible for the care of AV1-AV10 as a staff person working at the facility. Therefore, the SP was responsible for the maltreatment of the AVs. 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 physical abuse and neglect for which the SP was responsible was not serious because it did not meet the statutory criteria of serious maltreatment. The physical abuse and neglect for which the SP was responsible was not recurring maltreatment because it was considered a single pattern of behavior. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an Internal Review and found their policies and procedures adequate. All staff persons at the facility were retrained on behavior guidance. 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. Minnesota Statutes, section 260E.06, subdivision 1, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that six individuals failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures. On January 10, 2024, the facility was issued a Correction Order for the violations outlined in this report and for failure to comply with background study requirements. In addition, it was determined that facility mandated reporters including one mandated reporter in a management role had knowledge of the alleged incidents and did not report the incidents as required. The license holder was ordered to forfeit a fine of $200 for failure to report maltreatment. The Order to Forfeit a Fine 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.
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