Facility profile Virginia

Harbor Point Behavioral Health Center

Formerly Pines Residential Treatment Center (1988 to 2011)source

Open Portsmouth, Virginia

Harbor Point Behavioral Health Center is a residential treatment center in Portsmouth, Virginia, operated by Universal Health Services (UHS). It has operated since 2011.

About Harbor Point Behavioral Health Center

Psychiatric Solutions Inc. purchased by Universal Health Services in 2010 for about $3 billion.source It was run by Universal Health Services.source It was owned by Psychiatric Solutions Inc. (originally).source

Stays lasted roughly 6 months.source It originally operated three locations, two in Portsmouth and one in Norfolk.source

Timeline

From the records: who ran it and the deals that moved it, its names, and the deaths, incidents, inspection findings, lawsuits and news stories on file. Point at an event, or tap "More about this", for the details.

  1. 2011

    1. Opened

      Opened in Portsmouth, Virginia

    2. Incident

      Investigation

      Incident records show 50 fights or assaults among kids, two suicide attempts and 15 self-harm incidents from March to mid-April 2011, and the department had...

      Investigation

      Incident records show 50 fights or assaults among kids, two suicide attempts and 15 self-harm incidents from March to mid-April 2011, and the department had conducted more than 150 investigations at the center.

      source

    3. Incident

      License action

      Virginia's Department of Behavioral Health and Developmental Services suspended admissions to and downgraded the license of The Pines and its three other...

      License action

      Virginia's Department of Behavioral Health and Developmental Services suspended admissions to and downgraded the license of The Pines and its three other Hampton Roads facilities in 2011.

      source

    4. IncidentApril 2011

      Closure order

      After unreported injuries and sexual-abuse allegations surfaced in April 2011 the program was investigated and shut down, then reopened as Harbor Point.

      Closure order April 2011

      source

    5. IncidentApril 2011

      Investigation

      Virginia found The Pines failed to report a sexual abuse allegation; North Carolina suspended new admissions April 13, 2011 and reviewed 113 residents.

      Investigation April 2011

      source

  2. 2023

    1. Inspections

      State inspectors recorded 2 serious findings

      Physical abuse or assault, medical neglect.

      State inspectors recorded 2 serious findings

      Aug 7, 2023: Per provider's CHRIS report #A20230324, by a preponderance of the evidence which included eyewitness statements, failure to follow policy and witness credibility, the provider substantiated the allegation of neglect when Employee #1 used an improper restraint...

      Dec 19, 2023: Per provider's CHRIS report #A20230471, the provider substantiated the allegation of neglect with a preponderance of the evidence that included eyewitness statements and witness credibility when Employee #1 administered the following wrong medications to...

      Read the findings

  3. 2024

    1. Inspections

      State inspectors recorded 4 serious findings

      2 physical abuse or assault, self-harm, medical neglect.

      State inspectors recorded 4 serious findings

      Jul 25, 2024: Per provider's CHRIS report #20240318, based on a preponderance of the evidence which included witness statements, witness credibility and camera footage review, the provider substantiated the allegation of neglect when Employee #1 is observed hitting...

      May 28, 2024: At this time, Employee #1 is observed pushing Individual #1 to the floor.

      May 6, 2024: Per provider's CHRIS report #20240183, Individual #1 was able to gain access to a locked med room on the unit with a broken piece of plastic and allegedly ingested some old medication that they found inside a file cabinet in the med room.

      Read the findings

  4. 2025

    1. Inspections

      State inspectors recorded 4 serious findings

      3 physical abuse or assault, restraint or seclusion causing injury.

      State inspectors recorded 4 serious findings

      Nov 10, 2025: After reviewing camera footage of a behavioral incident that involved Individual #1 and Employee #1, it was noted that Employee #1 hit Individual #1 with a broom during a behavioral emergency.

      Jun 10, 2025: Per provider's CHRIS report #20250147, the provider substantiated the allegation of physical abuse when it was noted that Employee #1 threw a cup of water onto Individual #1 during a behavioral incident with Individual #1.

      Apr 14, 2025: Employee #1 displayed inappropriate actions by yelling and slightly shoving individual #1 in shoulder after she pushed him.

      Read the findings

  5. 2026

    1. Inspections

      State inspectors recorded 2 serious findings

      Physical abuse or assault, hospitalisation.

      State inspectors recorded 2 serious findings

      Mar 10, 2026: After reviewing camera footage of the incident and discussion with the provider, it was noted that Employee #1 was physically abusive towards Individual #1 during an altercation with Individual #1.

      Jan 6, 2026: During the physical altercation, 4 staff are observed responding to the altercation, however 2 of the 4 fail to respond appropriately with urgency and purpose resulting in the situation escalating, an individual taking control of one of the staff's walkie...

      Read the findings

As Pines Residential Treatment Center

1988 to 2011 | Universal Health Services (UHS), Psychiatric Solutions, Inc.

It closed in 2011.source

Incidents on record

  1. 2011 Investigation

    Incident records show 50 fights or assaults among kids, two suicide attempts and 15 self-harm incidents from March to mid-April 2011, and the department had conducted more than 150 investigations at the center.source

  2. 2011 License action

    Virginia's Department of Behavioral Health and Developmental Services suspended admissions to and downgraded the license of The Pines and its three other Hampton Roads facilities in 2011.source

  3. April 2011 Closure order

    After unreported injuries and sexual-abuse allegations surfaced in April 2011 the program was investigated and shut down, then reopened as Harbor Point.source

  4. April 2011 Investigation

    Virginia found The Pines failed to report a sexual abuse allegation; North Carolina suspended new admissions April 13, 2011 and reviewed 113 residents.source

As Harbor Point Behavioral Health Center

from 2011 | Universal Health Services (UHS)

Serious violations

Physical abuse or assault Inspected Aug 7, 2023

Per provider's CHRIS report #A20230324, by a preponderance of the evidence which included eyewitness statements, failure to follow policy and witness credibility, the provider substantiated the allegation of neglect when Employee #1 used an improper restraint with Individual #1 which caused Individual #1 to sustain an injury to their arm.

From the VA inspection report. Non-compliance, DBHDS human rights inspection Also: Restraint or seclusion causing injury State's report

Physical abuse or assault Inspected Mar 10, 2026

After reviewing camera footage of the incident and discussion with the provider, it was noted that Employee #1 was physically abusive towards Individual #1 during an altercation with Individual #1.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Physical abuse or assault Inspected Nov 10, 2025

After reviewing camera footage of a behavioral incident that involved Individual #1 and Employee #1, it was noted that Employee #1 hit Individual #1 with a broom during a behavioral emergency.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Physical abuse or assault Inspected Jun 10, 2025

Per provider's CHRIS report #20250147, the provider substantiated the allegation of physical abuse when it was noted that Employee #1 threw a cup of water onto Individual #1 during a behavioral incident with Individual #1.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Physical abuse or assault Inspected Apr 14, 2025

Employee #1 displayed inappropriate actions by yelling and slightly shoving individual #1 in shoulder after she pushed him.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Physical abuse or assault Inspected Jul 25, 2024

Per provider's CHRIS report #20240318, based on a preponderance of the evidence which included witness statements, witness credibility and camera footage review, the provider substantiated the allegation of neglect when Employee #1 is observed hitting Individual #1 during a behavioral crisis situation.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Physical abuse or assault Inspected May 28, 2024

At this time, Employee #1 is observed pushing Individual #1 to the floor.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Restraint or seclusion causing injury Inspected May 8, 2025

Per provider's CHRIS report #20250029, Individual #1 was injured during a physical restraint technique with Employee #1.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

4 more serious findings

Self-harm Inspected May 6, 2024

Per provider's CHRIS report #20240183, Individual #1 was able to gain access to a locked med room on the unit with a broken piece of plastic and allegedly ingested some old medication that they found inside a file cabinet in the med room.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Medical neglect Inspected Sep 5, 2024

Employee #1 failed to provide treatment necessary to the safety and welfare for Individual #1 and Individual #2 and as a result, Individual #1 and #2's right to be free from neglect was violated.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Medical neglect Inspected Dec 19, 2023

Per provider's CHRIS report #A20230471, the provider substantiated the allegation of neglect with a preponderance of the evidence that included eyewitness statements and witness credibility when Employee #1 administered the following wrong medications to Individual #1: Medications #1 - #4, which belonged to a peer.

From the VA inspection report. Non-compliance, DBHDS human rights inspection State's report

Hospitalisation Inspected Jan 6, 2026

During the physical altercation, 4 staff are observed responding to the altercation, however 2 of the 4 fail to respond appropriately with urgency and purpose resulting in the situation escalating, an individual taking control of one of the staff's walkie talkie and eventually Individual #1 being sent to the ER and the police are called to assist.

From the VA inspection report. Non-compliance, DBHDS human rights inspection Also: Police involvement State's report

Incidents on record

  1. Abuse

    Survivors report verbal abuse, violent and excessive restraints, untrained staff, sexual abuse, unsanitary conditions and harsh punishments.source

News coverage

  • The Royal Gazette Sep 29, 2026 Expose

    Tucker: ‘Turn every stone to keep children in Bermuda’

    Opposition youth services minister Robin Tucker questioned the Government's awareness of a U.S. Senate report detailing abuse at residential treatment facilities where Bermudian children in care have been placed. She called for greater oversight, local therapeutic options, and transparency regarding the Department of Child and Family Services' vetting and monitoring practices.

  • The Royal Gazette Sep 24, 2026 Expose

    Children sent to US facility after inquiry found failings

    A United States Senate Committee report identified multiple incidents of physical and verbal abuse, as well as sexual misconduct, at Harbour Point Behavioural Health Centre and other residential treatment facilities used for Bermudian children. The Bermuda Government stated that its child protection agency used Harbour Point only for assessment and denied that it placed children in residential treatment abroad, while acknowledging the facilities were selected by an overseas therapeutic programme committee.

Staff

Notable staff

Federal funding

Federal money this program received, as government records, congressional reports and news coverage show it.

Medicaid and federal child welfare funds

  • 2022-2024: Named in the U.S. Senate Finance Committee's June 2024 staff report "Warehouses of Neglect" (pp. 85), which covers youth residential treatment placements "funded through the Medicaid program and the Social Security Act's child welfare provisions" (p. 3). The report says Medicaid was 39 percent of Universal Health Services' behavioral health revenue in 2023 (pp. 28-29). source

Licensing and inspections

Licensed as
Harbor Point Behavioral Health
Program
909-14-003
License category
Psychiatric residential treatment facility (DBHDS)
Executive director
Kelly Barcroft
License expires
2028-04-30
Licensing action
Active, Triennial
Phone on file
(757) 391-5961
Licensed address
301 Fort Lane, Portsmouth, VA 23704

99 inspection reports on file. Search all Virginia reports

The newest 25 reports, by date: 13 findings in 13 reports
  1. Oct 30, 2026 Investigation: no violation Open report
  2. Oct 26, 2026 Investigation: no violation Open report
  3. Oct 26, 2026 Investigation: 1 standard cited Open report
    1 finding
    • Non-compliance, DBHDS investigation : 12VAC35-46-870. F. (2) Supervision policies: 2. At all times the ratio of staff to residents shall be at least one staff to eight residents for facilities ...

      At the time of review, multiple shifts without at minimum 1- 8 staff to individual ratios were identified on the following:6/24/2026 - Oasis C – 9 individuals to 1 staff on all three shifts, 6/27/2026 - Oasis C – 9 individuals to 1 staff on second awaking hours shift ,6/28/2026 - Oasis C – 9 individuals to 1 staff on second awaking hours shift ,6/29/2026 - Oasis C – 9 individuals to 1 staff on second awaking hours shift ,6/30/2026 - Oasis C – 9 individuals to 1 staff on second awaking hours shift, 7/1/2026 – Comp A - 9 individuals to 1 staff on all three shifts , 7/3/2026 – Oasis C – 9 individuals to 1 staff on second awaking hours shift , 7/6/2026 – Oasis C – 9 individuals to 1 staff on second awaking hours shift , 7/11/2026 – Comp A – 9 individuals to 1 staff on second awaking hours shift , 7/12/2026 & 7/13/2026 – Comp A – Data appears to be inaccurate (states 1 individual per shift receiving services). 7/16/2026 - Oasis C - 10 individuals to 1 staff on second awaking hours shift ,7/16/2026 - Oasis C - 10 individuals to 1 staff on first and second awaking hours shifts.

  4. Oct 26, 2026 Investigation: no violation Open report
  5. Aug 11, 2026 Death or Serious Incident Inspection: 1 standard cited Open report
    1 finding
    • Non-compliance, systemic, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

      Harbor Point Behavioral Health This regulation was NOT MET (SYSTEMIC) as evidenced by: CHRIS Number: 20260061 Date/Time of Discover: 07/25/2026 10:00AM Enter Date/Time: 07/30/2026 8:12PM Reporting Delay: 106:12:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260062 Date/Time of Discover: 07/25/2026 6:12PM Enter Date/Time: 07/30/2026 8:19PM Reporting Delay: 98:7:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260064 Date/Time of Discover: 08/07/2026 4:00PM Enter Date/Time: 08/09/2026 12:28PM Reporting Delay: 20:28:00 Location Name: Harbor Point Behavioral Health Note: As this is provider's second step in the Progressive Citation Cycle for the same regulation within a one-year period, measured on a rolling basis, provider has demonstrated systemic noncompliance. Provider was previously cited for late reporting • The first citation was issued on 11/18/25 and is now a non-compliant. • The second citation was issued on 12/4/25 and is now a non-compliant. • The third citation was issued on 2/4/26 and is now a non- compliant.

  6. Jul 22, 2026 Investigation: no violation Open report
  7. Jul 22, 2026 Investigation: no violation Open report
  8. Jul 21, 2026 Investigation: no violation Open report
  9. Jul 21, 2026 Investigation: no violation Open report
  10. Jul 6, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

      Abuse means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Per provider's CHRIS report #A20260162, based on a preponderance of the evidence which included staff admission, the provider substantiated the allegation of verbal abuse when it was discovered that Employee #1 was verbally abusive towards Individual #1. • As a result of Employee #1's actions, Individuals #1's right to be free from verbal abuse was violated.

  11. Jul 6, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

      Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • Per provider's CHRIS report #A20260161, based on a preponderance of the evidence which included staff admission, the provider substantiated the allegation of Neglect, failure to provide services necessary for health, safety and welfare. Employee #1 and Employees #2 failed to provider services that was consistent with the needs of the Individual #1. • As a result of Employee #1 and Employee's actions, Individuals #1's engaged in Self Injurious Behavior.

  12. May 28, 2026 Investigation: no violation Open report
  13. May 7, 2026 Investigation: no violation Open report
  14. May 6, 2026 Investigation: no violation Open report
  15. Apr 23, 2026 Investigation: 1 standard cited Open report
    1 finding
    • Non-compliance, DBHDS investigation : 12VAC35-46-870. D. There shall be at least one trained child care worker on duty and actively supervising residents at all times that one or more residents are ...

      At the time of review, there was no evidence of staff actively supervising residents and ensuring their safety.

  16. Apr 15, 2026 Investigation: 1 standard cited Open report
    1 finding
    • Non-compliance, DBHDS investigation : 12VAC35-46-870. D. There shall be at least one trained child care worker on duty and actively supervising residents at all times that one or more residents are ...

      At the time of review, there was no evidence of staff actively supervising residents and ensuring their safety.

  17. Apr 3, 2026 Investigation: 1 standard cited Open report
    1 finding
    • Non-compliance, DBHDS investigation : 12VAC35-46-870. D. There shall be at least one trained child care worker on duty and actively supervising residents at all times that one or more residents are ...

      At the time of review, there was no evidence of staff actively supervising residents and ensuring their safety.

  18. Apr 3, 2026 Investigation: no violation Open report
  19. Mar 31, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

      Abuse means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Per provider's CHRIS report #A20260009, based on a preponderance of the evidence which included staff admission, the provider substantiated the allegation of verbal abuse when it was discovered that Employee #1 was verbally abusive towards Individual #1. • As a result of Employee #1's actions, Individuals #1's right to be free from verbal abuse was violated.

  20. Mar 30, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3b) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

      • Per regulation 12VAC35-115-230(A)(3), the provider is required to "…provide a written report of the results of the investigation of abuse or neglect to the director and human rights advocate via the department's web- based reporting application within 10 working days from the date the investigation began unless an extension has been granted…" • As of 3/13/26, provider has failed to enter investigation findings within the required reporting timelines for the following CHRIS reports: A20250360, A20250364, A20250366 – A20250401, A20250403 – A20250411, A20260001, A20260002, A20260004 - A20260019, A20260021 - A20260026, A20260035 – A20260038, A20260046, which is in direct violation of this regulation.

  21. Mar 30, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-260. A. (11) Providers, through their directors, shall: 11. Cooperate with the human rights advocate and the LHRC to investigate and correct ...

      • Per regulation 12VAC35-115-260(A)(11), the provider is required to "Cooperate with the human rights advocate and the LHRC to investigate and correct conditions or practices interfering with the free exercise of individuals' human rights and make sure that all employees cooperate with the human rights advocate, the LHRC, and the SHRC in carrying out their duties under this chapter;" • As of 3/12/26, the provider has failed to respond to the citation/CAP issued for incident in provider CHRIS report #A20250378. The provider response was due to be entered into CONNECT by 1/29/26 which is in direct violation of this regulation.

  22. Mar 25, 2026 Investigation: no violation Open report
  23. Mar 10, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

      Abuse means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • After reviewing camera footage of the incident and discussion with the provider, it was noted that Employee #1 was physically abusive towards Individual #1 during an altercation with Individual #1. • Employee #1 is observed physically interacting with Individual #1 in an inappropriate manner when Employee #1 is observed pulling on Individual #1's legs while they are seated in a chair. This behavior then leads to Employee #1 and Individual #1 getting into a physical altercation where each person's hair is pulled. • Employee #1 is observed pulling Individual #1's hair in order to get Individual #1 off of her. • As a result of Employee #1's actions, Individuals #1's right to be free from abuse is violated.

  24. Feb 3, 2026 Death or Serious Incident Inspection: 1 standard cited Open report
    1 finding
    • Non-compliance, systemic, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

      Harbor Point Behavioral Health This regulation was NOT MET (SYSTEMIC) as evidenced by: CHRIS Number: 20260003 Date/Time of Discover: 01/18/2026 7:36AM Enter Date/Time: 01/21/2026 11:06AM Reporting Delay: 51:30:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260004 Date/Time of Discover: 01/18/2026 7:36AM Enter Date/Time: 01/21/2026 11:10AM Reporting Delay: 51:34:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260005 Date/Time of Discover: 01/18/2026 7:36AM Enter Date/Time: 01/21/2026 11:16AM Reporting Delay: 51:40:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260008 Date/Time of Discover: 01/22/2026 5:00PM Enter Date/Time: 01/26/2026 9:38AM Reporting Delay: 64:38:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260009 Date/Time of Discover: 01/24/2026 2:11PM Enter Date/Time: 01/26/2026 1:28PM Reporting Delay: 23:17:00 Location Name: Harbor Point Behavioral Health CHRIS Number: 20260018 Date/Time of Discover: 02/10/2026 10:20PM Enter Date/Time: 02/12/2026 11:35AM Reporting Delay: 13:15:00 Location Name: Harbor Point Behavioral Health Note: As this is provider's second step in the Progressive Citation Cycle for the same regulation within a one-year period, measured on a rolling basis, provider has demonstrated systemic noncompliance. Provider was previously cited for late reporting • The first citation was issued on 6/18/25 and is now non- compliant.

  25. Jan 30, 2026 Human Rights Inspection: 2 standards cited Open report
    1 finding
    • Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

      Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • After reviewing camera footage of the incident and discussion with the provider, it was noted that Individuals #1, #2, and #3 eloped from the building after one of the individuals obtained Employee #1's keys that were left hanging from the door lock on the wall near the unit hallway exit. • Per provider's report to the Human Rights Advocate, Employee #1 was observed by the individuals leaving their keys hanging from the door lock multiple times and Employee #1 admitted after the incident that one of the individuals commented about it to him. • Individuals #1, #2 and #3 used Employee #1's keys to exit their unit and move into another unit where they then exited the second unit to a main hallway that then led out to the lobby area and the building's main exit. Upon entrance to the lobby, there were no provider staff present at the front desk, and the individuals exited the building. • As a result of Employee #1's actions, Individuals #1, #2 and #3's right to be free from neglect was violated.

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