Severe reports

Spoke with [Former client 3] again and this time she reported staff #1 slammed her head into the wall and staff #2 pulled her by hair and pushed her back on couch [...] [Former client 3] reported that both staff #1 and staff #2 assaulted her Interviews on 7/22/26 and 7/27/26 the Director reported: She was aware that [Former client 3] reported that staff #1 hit her to her DSS legal guardian [...] She did not know that the allegation from [Former client 3] required an IRIS because the police had not been called

From the state's report. Deficiency cited, complaint survey. Cited: V 367| 27G .0604 Incident Reporting Requirements. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A former client reported that a staff member put arms around the neck, lifted, and slammed the client to the ground. The client left the facility, and the guardian later reported the client had injuries and police involvement. Our summary of the state's report. The state's own wording follows.

"[Staff #9] went behind and put his arms around my neck picked me up and slammed me to the ground." [...] [Former client 7] eloped from the facility. [...] We (facility staff) called the police after the 2nd time [Former client 7] left. After the police left, he and staff #9 finished the shift. [...] Approximately one hour later around 4pm, [Former client 7]'s legal guardian/mother called and said Emergency Medical Services (EMS) and law enforcement made contact with [Former client 7] and he had an injury to his forehead and shoulders. [...] She had not called law enforcement because [Former client 7] “had already made contact with them (law enforcement)." [...] She received a call from the Assistant Program Director who informed her [Former client 7] had eloped and a handgun was involved " proceeded to the house (facility)." [...] She was told when [Former client 7] saw staff #9's handgun he left the facility and threw the metal somewhere on the side of the road.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: { summary: Six staff members failed to protect a child who had a history of self-harm. The child was found hanging in a bathroom and died by suicide. } Our summary of the state's report. The state's own wording follows.

Based on observation, record reviews and interviews, 6 of 8 audited paraprofessional staff (#1, #2, #4, #5, #6 and #9) failed to protect client from harm and neglect affecting 1 of 1 deceased client ([Deceased client 9]). [...] "She has an extensive history of self-injurious behaviors, suicidal ideation and at least three reported suicide attempts." Review on 3/19/26 of the North Carolina (NC) Incident Response Improvement System (IRIS) revealed: [...] "On March 15, 2026, (Executive Vice President) received a call from Chief Executive Officer (CEO) informing me that a client [Deceased client 9] had attempted suicide at the Cornerstone Treatment Facility (facility). [...] "Staff reported that [Deceased client 9] was found ina bathroom hanging from the shower curtain rod by a ligature. [...] "Based on all information gathered, [Deceased client 9] died as a result of suicide by ligature. [...] "She [Deceased client 9] had previously cut herself a week or two before this incident."

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

On 4/17/26, Former Staff #1 hit him in the stomach [...] Left the facility on 4/18/26 and on 4/19/26 because on 4/17/26, Former Staff #1 hit him in the stomach Review on 4/23/26 of the Incident Response Improvement System (IRIS) revealed:

From the state's report. Deficiency cited, annual and complaint survey, Type A2 violation. Cited: V 366. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: { summary: A former client damaged an office door while a staff member called the emergency services. The staff member and former clients reported that physical fights and verbal threats occurred between them. The staff member confirmed he accidentally hit a former client in the face during the commotion. } Our summary of the state's report. The state's own wording follows.

While staff #1 was on the telephone with 911, [Former client 2] caused property damage by punching and kicking the office door. [...] "Staff #1 punched me in my face and ended up with a busted lip and messed up eye." [...] They had stopped fighting but staff #1 kept “talking junk" and punched his brother in the face and they started fighting again. [...] "He [staff #1] would jokingly say how he would hurt me and my brother- how he would choke us out, stab us, shoot us, try to kill, punch us and slam us against the wall. [...] Staff #1 punched [Former client 1] trying to get to him. [...] "[Staff #1] hit my brother to get to me. He (staff #1) hit me and we started fighting." [...] "[Staff #1] called the police." Cc [...] The kid said something about his mom, [staff #1] punch the kid. [Staff #1] don't hit first unless he have to. can't recall the name of the kid." [...] Staff #1 confirmed he did hit [Former client 1] open handed by accident in the face in all the commotion.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: { summary: A child in the program reported that two staff members punched, choked, and spit on her. The program did not suspend the staff members while looking into the claim, and reports to the state registry were delayed. } Our summary of the state's report. The state's own wording follows.

4/23/26 revealed: 3/31/26, Former client (FC) #6 self-injurious behaviors (SIB)/suicidal ideation (SI!) 4/1/26, [Former client 6], SI and elopement 4/2/26, the facility was notified by CPS of client #1's allegation that she was punched and spit on by staff #9 and staff #2 during an incident on 4/15/26, client #4, attempted elopement and jumped out of a moving van 4/16/26, client #1 altercation with peer (client #4) over use of colored pencils; physical altercation between client #1 and client #3; client #1 physical aggression with staff; restrictive intervention due to hitting, spitting on and biting staff (staff #1), and included allegation that staff #1 was abusive and hit client #1 multiple times. [...] One Suicide Attempt, suspect (Former client #6) on scene on 3/31/26. [...] One Physical Assault, suspect on scene on 6/16/26 (client #1). [...] 4/18/26, submitted on 4/21/26, clients #2 and #3 elopement.

"Internal Investigation Summary: On April 2,2026, a social worker (Department of Social Services Investigator) contacted Executive Director [ED/Licensee] and reported that [client #1] alleged she had been physically assaulted by staff (#2 and #9), specifically stating that [staff #2] choked her and [staff #9] punched her in the face An internal investigation was initiated following this report. [...] No documentation of HCPR notification for client #1's allegation that staff #2 and staff #9 "choked and punched client #1 in the face" and spit in client #1's face. [...] "It wasn't until she (client #1) bit me (staff #2) that [staff #9] pinched her (client #1) nose...(client #1) had my arm...[client #1] bit me twice, she had my arm in her mouth until [staff #9] was pinching her (client #1] nose." She and staff #9 were together during the incident, "[Staff #9] never hit her (client #1)."

Had not been suspended nor received any disciplinary action regarding client #1's allegation that staff #2 and #9 choked, punched and spit on client #1. [...] She worked on 3/19/26 and was in the back of the facility with the other clients (#1, #2, #4, #5, and [Former client 6]) during the incident when client #1 alleged that staff #2 and #9 choked, punched and spit on client #1. [...] The ED/Licensee completed the HCPR report for client #1's allegation that staff #2 and #9 choked, punched and spit on client #1.

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367] 27G .0604 Incident Reporting Requirements; V 132; V 132. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

"They (staff) put you on 1:1 when you self-harm." [...] Clients were placed on 1:1 "only when you do self-injurious behaviors." [...] "On my 3rd day (1/27/26), there was an incident where [Former client 6] got into the kitchen and grabbed a knife and threatened me. had to remove another client (#5) and took her to [sister facility A] and [Former client 6] cut herself." [...] During an incident on 1/27/26, [Former client 6], who needed 1:1 supervision, was able to obtain a knife and use it to cut herself. [...] Staff #7 left the clients on the van with the Staff #2, who was shadowing, and then later, while [Former client 6] was agitated, left the facility without a backup staff to relieve her.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 315) 27G .1902 Psych. Res. Tx. Facility - Staff. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Type of Incident: "suicide attempt, suicide gestures, self-harm, aggression, property damage;" [...] At approximately 1:55 PM, law enforcement arrived and assumed control of the scene. [...] At approximately 2:05 PM, Emergency Medical Services (EMS) arrived. Law enforcement escorted the client to he ambulance. [...] AP arrived at the facility when [Client #1] was getting ready to be transported by EMS to the local hospital on 1/4/26; "She (Executive Director/Licensee) told me to tell the police that the other staff was gone to get something to eat" on 1/4/26;

Psychiatric hospitalization or crisis stabilization admission; [...] On 1/4/24, Staff #1 was at the facility alone with Client #1, when she started to have Cc aggressive behaviors, and inflicted self- harm by cutting herself with glass. [...] EMS transported client to local hospital.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.; V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" marks text left out between sentences.

Review on 11/26/25 and 1/16/26 of law enforcement call log from 9/1/25 through 1/13/26 revealed: [...] 9/20/25, 18:21 (6:21pm), MP-RUNWY (missing person-runaway) REPORT; [...] 12/11/25 13:27 (1:27pm), DV-ASLT (domestic violence-physical assault), SUSP-SCN; [...] 9/18/25, client #3 eloped, submitted on 9/22/25. 9/22/25 client #3 eloped, submitted on 10/2/25. [...] Purpose of Investigation: The purpose of this investigation is to review and assess allegations made by consumer, while in hospital for behaviors. [Client #2] alleged inappropriate staff conduct, including inappropriate touching, staff being under the influence of drugs, and staff fighting while on duty.

From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 367. "[...]" marks text left out between sentences.

In plain words: { summary: A child in the program used a razor to self-harm after staff talked with her. A former child in the program left the group home, returned, and used a rusty nail to self-harm. } Our summary of the state's report. The state's own wording follows.

10/10/25- Client #3's self-harm incident. 10/17/25- Client #3's AWOL, police involvement and hospitalization. [...] 10/31/25- [Former client 4]'s AWOL, police involvement and hospitalization incident. [...] The staff called the non-emergency police line." [...] The staff continued to process with [Client #3]. [Client #3] ate breakfast and went back to her room. [Client #3] kept her personal razor and broke the razor out of it, using it to self-harm. [Client #3] walked back up to the staff, showing them her arms. [...] After talking with them, [Former client 4] went AWOL at 6:47 pm and was brought back to the group home by [Local County] EMS (Emergency Medical Services) around 7:30 pm. [...] Once back at the group home, the staff monitored and followed [Former client 4] throughout the house. [Former client 4] found a rusty nail while she was AWOL the first time and used that to self-harm. [...] Staff reported that [Former client 4] hit the tree and the ground hard.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367| 27G .0604 Incident Reporting Requirements. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: { summary: A child in the program alleged that one staff member slapped her in the face before two staff members put her in a restraint. The state found that the child was scratched during the restraint, and there was no record of an internal investigation. } Our summary of the state's report. The state's own wording follows.

There was no documentation of an internal investigation for the incident that took place on 11/9/25 when Client #7 alleged Staff #5 slapped her in the face before Staff #5 and Staff #6 put her in a restraint for aggressive behavior. [...] "[Client #7] pushed her (Staff #5) back and [Staff #5] slapped her (Client #7)." [...] "After she (Staff #5) slapped [Client #7], they (Staff #5 and Staff #6) tried to restrain her (Client [...] Cc "[Client #7] pushed [Staff #5] and [Staff #5] slapped her in the face." [...] She was restrained for being aggressive and she received the scratch on her face while being combative during the restraint."

On 11/9/25 Client #7 had to be restrained due to aggressive behavior, and alleged Staff #5 slapped her in the face causing a scratch on her (Client #7) cheek. [...] It was determined Client #7 was scratched on her face due to a restraint. [...] On 11/9/25 Client #7 alleged Staff #5 slapped her and scratched her cheek. [...] Based on Client #7's history of assaultive behavior, she determined that "[Client #7] scratched herself as she struggled with staff (Staff #5 and #6) during the restraint." Cc

From the state's report. Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint survey. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect; V 132} G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.

"[Staff #1] called out my name and crawled under and went back to my stall and hit my head on the toilet paper thing." [...] "Three minutes later [client #2] came out, running out of the bathroom saying that [client #3] raped him in the bathroom. [Client #3] said the opposite that [client #2] tried to rape him." [...] "Staff full name: [staff #1]" Review on 11/20/25 of [Former client 5]'s medical records from local urgent care revealed:

From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 293] 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A former client reported having an inappropriate sexual relationship with a staff member that started at the facility and continued after the client left. The facility rules strictly forbid staff from having personal or sexual relationships with clients. Our summary of the state's report. The state's own wording follows.

"Staff members who engage in romantic or sexual relationships with clients are abusing their power and can be seen as taking advantage of their clients." [...] "Employees are prohibited from engaging in a personal relationship, including any type of sexual contact, with clients." [...] Mid Year Employee Evaluation completed by the DON and dated 8/12/25 included, "...does have 4 medication errors at the present time...completed medication review refresher in 3/2025...has been challenged to stay focused and focus on his responsibilities." [...] He informed Staff #1 to not contact him anymore on 9/12/25 because he felt like Staff #1 hadn't loved him and only wanted a sexual relationship; [...] Based on what [Former client 5] had informed him in September 2025 (exact date unknown) Staff #1 and [Former client 5] had an inappropriate relationship that began while the client was at the facility and continued after the client was discharged;

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Category A providers shalt send a copy of alt evel III incidents involving a client death to the Division of Health Service Regulation within 72 hours of becoming aware of the incident.

From the state's report. Deficiency cited, complaint survey. Cited: V 296' 27G .1704 Residential Tx. Child/Adol - Min..

In plain words: A former client refused to be searched, threatened to run away, and left a message claiming abuse. He then walked out, threatened to kill the director and the director's family, and attacked another child in the program. The report also notes two suicide attempts outside the facility. Our summary of the state's report. The state's own wording follows.

Is attempting suicide outside (facility). [...] 7/21/25 4:00pm "...Once arrive to the house (facility) he ([Former client 5]) refused to get searched staff had to ask him repeatedly to get searched it's required staff directed him to go to his room he refused to and grabbed the house and demanded staff to call his social worker or he's running away staff called the social worker number [Former client 5] then left a message stating that he has been rapped and help him he is being molested and demanded help now...([Former client 5]) walked out the door while staff was talking to the other client and demanded staff to give him [Executive Director (ED)]'s address so he([Former client 5]) can go to his (ED) house and kill and take his (ED)whole family out...He ([Former client 5]) then ran to the other client (#2) room door and kicked it open and attacked the other client (#2). [...] 7/12/25, Attempted to hang himself in the backyard of the facility;

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367|. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Incident Summary- "On May 27, 2025, Client [Client #1] disclosed to staff that she was sexually assaulted by a peer, Client [Former client 3], during a supervised group outing to the YMCA on May 23, 2025. [...] Was physically assaulted by [Former client 3] while in the hot tub at the local YMCA;

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 293. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program reported that a staff member hit the child in the nose, grabbed their shirt, threw them down, dragged them on the ground, and forced them to exercise for hours. Our summary of the state's report. The state's own wording follows.

"[Staff #1], last week me and him got into it (staff #1 hit client #2 in the nose causing a nosebleed. [...] Staff #1 grabbed client #2 by the collar of his shirt and pulled him from the ground. [...] "He (staff #1) threw me down (to the ground) a couple of times, and drug me on the ground." -[Staff #3] was out there (in the backyard). [...] He (staff #1) hit me on my nose. [...] Staff #1 pushed him down and drug him on the ground (unknown dates). "He (staff #1) pushed me down and dragged me across the ground. don't know twice, more than twice, a lot of times. [...] On 3-4-25 as a consequence for client #2 hitting one of his school peers on the school bus earlier hat day, client #2 reported staff #1 hit him in his nose causing his nose to bleed and later forced him to exercise from approximately 2:30pm to 5:30pm.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

He put staff #2 in a headlock and staff #2 picked him up and "slammed" him to the ground outside of his room in the hallway. [...] Staff #2 admitted he shoved client #2 and took client #2 down to the floor by sweeping client #1's feet from under him which resulted in client #1 falling down on to the floor.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.

On 9/22/24 Client #1 tried to elope and was laken to the hospital for evaluation. [...] Client #1 told hospital staff that Staff #1 pushed her and denied her water. [...] Staff #1 came and pushed her back into her bedroom.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 132) G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.

Staff (Staff #1) then tried to open the door and realized that there was something pushed a against the door. [...] "Arrestee Information: [Staff #1]. Type of arrest: Taken into custody. [...] Charge #1: Rape- 2nd degree. [...] Charge #3: Statutory rape of a child <15 or =15. [...] He (Former Client #6) then asked [Staff #1] if he wanted him to do oral sex on him. [Former Client #6] then performed oral sex on [Staff #1]. [Staff #1] ejaculated in client's mouth. [Staff #1] then cleaned himself with [Former Client #6]'s shirt. [Former Client #6] afterwards told [Staff #2] at the facility." [...] " then ran away from the home (facility) and Cc went to the police." Facility staff called the police when he ran away. He told police there was evidence. [...] Later that day, Former Client #6 informed Staff #2 about the sexual abuse. [...] Staff #1 was charged with Rape- 2nd degree, Indecent Liberties and Statutory rape of a child <15 or =15.

From the state's report. Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint survey. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect; V 132) G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.

In plain words: A staff member bit a child on the shoulder to make the child let go of the staff member thumb. The child reported that the staff member put him in a chokehold and threw him on a bed, and that the child bit the staff member to get away. Another staff member called the police, and the child went to the hospital. Our summary of the state's report. The state's own wording follows.

Staff #1 bit Client #1 on the left shoulder to get Client #1 to release his bite on Staff #1's right thumb. [...] "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Vv 514 iss Mir flo( MX 25, hon (Kasi yeahs CDK911 If continuation sheet 5 of 9 Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed: [...] Called the police and Client #1 was transported to a local hospital for a mental health evaluation for his aggressive behavior [...] In an attempt to get Client #1 to release his bite, Staff #1 bit Client #1 on the left shoulder.

"He (Client #1) said [Staff #1] pulled him by the shirt and threw him on the bed, breaking the bed, then he (Client #1) grabbed a piece of wood from the broken bed and defended himself against [Staff #1]." "According to [Client #1], [Staff #1] tried to put him in a chokehold and he (Client #1) bit [Staff #1] in an attempt to get out of the chokehold Client on Cc when [Staff #1] bit his shoulder." " don't believe he (Staff #1) bit [Client #1] maliciously." Interview on 7/9/24 with Staff #2 revealed:

From the state's report. Deficiency cited, complaint survey, Type A2 violation. Cited: V514 ugetn; V 514) 27E .0102 Client Rights - Prohibited Procedures Vv 514. "[...]" marks text left out between sentences.

[Former client 4] stated the staff had been making "sexual advances toward him for the last 2 month."

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 132. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Received pictures the night of 1/11/24 "showing Cc Cc marks on his ([Former client 2]'s) neck ...think they were obtained during the restraint;"

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

He came in my office last Friday and showed me and he said she (staff #1) choked me said we talked last week, and you said you were playing.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect.

" called her ‘an old hag’ again and she (staff #1) said, ‘why don't you run (hit) to your old hag (repeated this twice).' asked her, ‘are you talking about my grandma?" " started crying. [Staff #2] had moved to the left side of her (staff #1). started yelling at [staff #1], ‘you do not know who you are messing with.' She (staff #1) pulled at her pants, like she was Cc squaring off (getting into a fight stance) and said, ‘you messed with the wrong one today.’ Then she (staff #1) said something, don't remember what she said, but it triggered me. punched her in her cheek. was aiming for her eye. thought had punched her in her eye but later heard her telling [Staff #2] hit her on her cheek." [...] "l walked down the hallway and yelled to [Staff #1], ‘I'm sorry [Staff #1], didn't want to hit you, _ didn't want to hurt you but you scared me.' She (staff #1) didn't respond."

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512 27D .0304 Client Rights - Harm, Abuse, Neglect V.512 Tame diate \y ‘. "[...]" marks text left out between sentences.

In plain words: A staff member allegedly slapped and punched a child in the face, causing a bloody nose, and threw the child onto a couch during an incident over a phone call. Our summary of the state's report. The state's own wording follows.

In doing so staff hand hit clients nose causing it to bleed. [...] "[Client #4] said [staff #1] punched me and threw me on the couch and sat on him." [...] "[Client #4] kind of lunged at [staff #1] and brought back his hand to scare [staff #1]. [Staff #1] slapped [client #4] on the face and that caused him to fall back on the couch. Then [staff #1] kept slapping [client #4] in the face a pretty good amount of times.” [...] "He (staff #1) assaulted a minor and now he is working again. [...] Staff #1 hit him with an "open hand." Interview on 4/9/24 with client #4 revealed: [...] Staff #1 then "yanked" the phone out of his hands and his phone call was disconnected. [...] "I guess he (staff #1) thought was going to hit him.” "He (staff #1) slapped me with an open hand 1 time (on his face) and fell back on the couch because of how hard he hit me." [...] "[Staff #11] asked me what happened and told him [staff #1] started punching me."

From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V512, 27D .0304 Client Rights - Harm, Abuse, Neglect v512 Each staff member was required to review the. "[...]" marks text left out between sentences.

Client #1 was sitting in a chair in the facility kitchen when staff #1 grabbed her by her shirt and pulled her off a chair causing her to fall to the floor.

From the state's report. Deficiency cited, annual and follow-up survey, Type A1 violation. Cited: V 512.

In plain words: A former client said two staff members sexually assaulted her while they were trying to get her phone back. The report says there is no documentation of an investigation or of protective measures being put in place. Our summary of the state's report. The state's own wording follows.

No documentation of an investigation into the allegations made by Former Client (FC) #7 that Staff #3 and Staff #4 sexually assaulted her on No documentation to support systems were put MHL0601558 Be WING 01/03/2024 in place to protect clients during an investigation after sexual assault allegations were made against Staff #3 and Staff #4 on 10/20/2023. [...] Description: Client ([Former client 7]) stated that staff (Staff #3 and Staff #4) were sexually assaulting her when staff were trying to get the phone back from the client. [...] Type of incident: Client/Staff Sexual Assault Allegation. Synopsis of incident: On Friday 10/20/2023 Client ([Former client 7]) stole staff phone and ran into her bathroom... and was making statements that staff (Staff #3 and Staff #4) were sexually assaulting her while she was in the bathroom. [...] The allegation of sexual assault incident with [Former client 7] occurred on 10/20/2023.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 132 G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: The state found that two staff members, a house manager, and the licensee neglected the needs of two former clients after one reported being sexually assaulted by the other. Staff did not get medical care for the victim and doubted the report. Our summary of the state's report. The state's own wording follows.

Finding #5: Evidence Staff #1, Staff #5, the HM, and the Licensee neglected [Former client 2] and [Former client 3]'s needs after an allegation of sexual abuse made by [Former client 2] against [Former client 3]. [...] "Allegation of sexual abuse reported 9/10 (9/10/23) ...Additional steps of safety plan were taken. [...] No medical care or evaluation completed after an allegation of sexual assault and vaginal penetration with a make-up brush. [...] On 9/9/23 between 9:30 pm and 1:00 am "She [Former client 3] raped me. ..." [...] Reported the sexual assault on 9/10/23 to Staff #1 and Staff #5, "They didn't really believe me." [...] Had [Former client 2] and [Former client 3] write a grievance and spoke to both of them about the alleged sexual assault. [...] Reported the sexual assault grievance made by [Former client 2] to the HM on 9/11/23. [...] On 9/10/23, Sunday, [Former client 2] said to her '[Former client 3] raped' her ... told her she had to talk to [the Licensee] ..."

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Staff #1 grabbed Client #1 by the shirt from behind with one hand and walked him over to a chair, then shoved him down into the chair; [...] Staff #1 grabbed Client #1 by the wrist, then tried to grab his other hand, Client #1 was moving around, Staff #1 then took about 2 steps and dragged Client #1 while Staff #1 was walking, he stopped and tried to get Client #1 to stand up on his feet, Client #1 was moving all around on the floor; [...] Staff #1 started to walk toward the outside door while he held Client #1's wrist, Client #1 fell to the floor and Staff #1 took about 6 steps while dragging Client #1 on the floor; [...] The allegations include The Village House staff choking and neglecting clients at the YMCA." [...] Staff #1 "dragged" client #1 out of the pool; [...] Staff #1 dragged the client (#1) out the back door.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.

"On 4/22/23, at approximately 1933 (7:33 p.m.), [Officer] responded to [County Hospital] for a sexual assault case. [Officer] spoke with [Former client 1] who stated that he had been sexually and physically assaulted at the Just in Time Youth Services home. [...] A couple of days after the incident, [Staff #2] approached [Former client 1] again in his room. [Staff #2] began to take his hand and feel [Former client 1's] thigh. [Former client 1] stated that he was wearing pants that had a button on them, but that it did not actually button. [Staff #2] tried unbuttoning his pants, realized he did not need to, then slipped his hand down [Former client 1's] pants. [Staff #2] then began to fondle [Former client 1's] penis. -[Former client 1] could not give much detail about what exactly had occurred.

From the state's report. Deficiency cited, complaint survey. Cited: V 132. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

[Former client 6] was hospitalized and sustained a "broken jaw a deep gash over her eye as well as an injury to the back of her head." Review on 5/2/23 of police report revealed: [...] "[Sheriff Deputy] was never dispatched to disturbance here. [...] Three staff (she, staff #3 and [Former staff 8]) were working at the sister facility A when [Former client 6] was hit by the car. [...] The fourth staff member who should have been working was at the store when [Former client 6] was hit by a car.

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A staff member pushed a child onto a bed and punched the child in the face, leaving a mark and causing pain. Police came to the home after the child texted a friend about another staff member. Our summary of the state's report. The state's own wording follows.

Client #2 eloped from the facility. [...] He had eloped from the facility about 3 times. [...] Staff #1 had pushed him to the bed and punched him in the face a couple months ago. Law Enforcement (LE) responded to the home after he texted a friend about staff #6. [...] Staff #1 stated "you want to kick the wall." Client #1 said "why are you hurting me?" Staff #1 said “you ain't got no money you ain't going to do no Property damage, You ain't kicking no doors and walls. [...] Staff #1 pushed him to the bed and “punched” him in the face once [...] He had a mark on the right side of his face from being punched by staff #1. He was in pain for about 2 days after he was punched by staff #1. [...] Staff #1 "pushed" client #1 onto the bed. [...] There was an allegation a staff hit a client in the jaw. [...] The CPS worker said the allegation was a 40 year old male, who she identified as staff #1, had body slammed client #1.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 366] 27G .0603 Incident Response Requirments V 366 | |. "[...]" marks text left out between sentences.

Assessment dated 1-6-23 revealed: escalating aggression...3 hospitalizations since 922- 22...attacked his grandparents...attacked school officer. [...] The Maintenance Director reported that he saw Staff #1 yelling, kicking, grabbing Client #3 around the neck and slamming him against the bathroom wall. [...] Phone interview on 1-27-23 with Client #3 revealed: "He (Staff #1) slammed my head into the wall and it hurt me.”

Stated that Staff #1 had grabbed him around his neck and threw him against the wall. [...] Staff #1 grabbed Client #3 by the throat from the front with one hand and slammed him into the wall. This was in Client #3's bathroom and it broke the sheetrock in the bathroom when Staff #1 slammed Client #3's head against the wall.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512 Vv 512; V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

In plain words: A former client reported to a school counselor that the chief executive officer was too rough during a physical hold. The report stated this caused bruises on the arms and legs and pain in the head and buttocks. Our summary of the state's report. The state's own wording follows.

An investigation had been completed this month (July 2022) regarding a client (former client (FC) #2) who made an allegation that the Chief Executive Officer/Qualified Professional (CEO/QP) physically abused him; [Former client 2] had reported to his school counselor (5/27/22) that the CEO/QP was too rough when he restrained him which resulted in bruises on his arms and legs and pain in his head and buttocks.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 132. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program reported that a staff member pinched and kicked them following a restraint. The state reviewed video and interviews and found evidence that the staff member appeared to kick or try to trip the child. Our summary of the state's report. The state's own wording follows.

Supervisor reports that she was emailed Sunday evening (did not read until on duty Monday) regarding an unauthorized restraint and staff pinching the client. [...] The email stated, "Hi was rounding today by phone [unidentified person] and [Client #3] (A) made an allegation that a staff [Staff #2] pinched him and put him a restraint yesterday. have not given a restrain order this weekend and wanted to pass this along for administration to check on it ... [...] Incident (s): The [Client #3] met with his [therapist] on 3/21/22 and reported that a staff member [Staff #8] kicked him following a restraint on 3/18/2022. [...] Conclusions: Based on interviews with staff, consumer, and review of the video there is evidence to show that staff member [Staff #8] placed her foot out appearing to kick or try to trip the consumer. [...] "[Staff #8] kicked me." Interview on 05/04/2022 with Staff #6 revealed:

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

In plain words: A child in the program reported having sex with another child in the game room and closet while a staff member sat nearby with their back turned. The report also states that a staff member threw a water bottle and bumped into a child with her body. Our summary of the state's report. The state's own wording follows.

"it would be different staff." Interview on 3/28/22 with client #6 revealed: -had a hickey from her boyfriend; -client #5 was her boyfriend; -had sex with client #5 in the game room; -client #4 was with them; -staff was at the table in front of the entrance to the game room; -staff had their back to them; -had sex twice in the game room closet with client -second time staff were in the same place when she and client #5 had sex; -don't remember what staff was working; -in the closet for five minutes both times. [...] Clients #1, #2, #3, #4, #5 and #6 displayed behaviors which included sexualized behaviors, substance abuse, aggression, self-harm, suicidal ideation, impulsivity, poor boundaries and criminal activity. [...] Staff #3 threw a water bottle and bumped into client #2 with her body.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 293. "[...]" marks text left out between sentences.

In plain words: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.

8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A staff member reportedly choked a child and bent the child's back over a sink. On another occasion, the staff member punched a hole in a child's bedroom wall out of frustration. Our summary of the state's report. The state's own wording follows.

"He (staff #8) did choke me." [...] Staff #8 punched a hole in his wall. [...] Staff #8 did not punch a hole in the wall. [...] Staff #8 choked client #1 and bent his back over the sink. [...] On another occasion staff #8 got frustrated with client #2 and punched a hole in client #2's bedroom wall.

Staff #8 had a family member that recently died from cancer. He thought staff #2 was at the facility when staff #8 punched his wall. Staff #2 punched the wall just above his head and it was patched.

Staff #8 had a family that recently died from cancer. He thought staff #2 was at the facility when staff #8 punched his wall. \- Staff #2 punched the wall just above his head and it was patched. ~ Staff #8 was also involved with an incident with client #1 in October. "He (staff #8) choked [Client #1] out."

The Licensee/Qualified professional (L/QP) was aware of staff #8 punching client #2's wall while client #2 was in his bed due to frustration from the client's behavior. [...] The DSS Social Worker did not tell him about an allegation staff #8 choked client #1.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation; Deficiency cited, annual, complaint, and f. Cited: V 512; V 132} G.S. 131E-256(G) HCPR-Notification,; V 512; V 366. "[...]" marks text left out between sentences.

There was an incident report dated 3/28/21 for deceased client ([Deceased client 4]).

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Client #1 revealed: "Friday (10/8/21) at around dinner time ...staff (Staff #2) pushed me into the corner of the room under a shelf near window (back right corner) ...I attempted to go in another direction ...staff ...bent wrist in the process to stop client assault. [...] Was working light duty after sustaining an injury in a restraint;

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.

3/30/21 Inappropriate Sexual Behavior: [Former client 1] reported to staff that she had been forced to have oral sex with someone while at school.

From the state's report. Deficiency cited, complaint survey. Cited: V 367. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: State inspectors found the facility failed to provide proper treatment, keep continuous watch during sleep hours, and follow its licensed capacity limit. The facility also failed to create plans to address behaviors such as running away, sexualized actions, and self-harm. Our summary of the state's report. The state's own wording follows.

Based on observation, interview and record review the facility staff failed to provide intensive, active therapeutic treatment and interventions to ensure safety and to minimize the occurrence of behaviors, failed to assure staff were providing continuous supervision during sleep hours and failed to operate within the scope it was licensed for by admitting a 5th client while it was operating at its licensed capacity of 4 clients affecting 2 of 2 current audited clients (#1 #2), 2 of 2 current unaudited clients (#3 #6) and 2 of 2 former clients ([Former client 4] [Former client 5]). [...] Based on interview and record review, the facility failed to develop and implement strategies and interventions within a treatment plan to address behaviors of elopement, sexualized behaviors and self injury affecting 1 of 2 former clients ([Former client 4]).

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Staff #1 conducted an inappropriate restraint on client #3 face down on the couch. Client #4 was injured during the physical altercation and required six stitches for a laceration above her eye.

From the state's report. Deficiency cited, follow-up survey, Type A1 violation. Cited: {V 293}.

"staff were in a crisis." -kid called staff the "n word" and other kid ran in kid's room and beat him up.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A violation. Cited: V 314) 27G .1901 Psych Res. Tx. Facility - Scope.

Discharge Summary completed by Licensee #1/Director/Qualified Professional #1 dated 8/6/20 revealed stealing peers' clothing, struggling with telling the truth, physical assault by pushing a peer off the couch, and a sexual assault allegation;

No incident reports regarding an allegation of abuse involving Staff #8 choking Former Client Interview on 8/10/20 with Licensee #1/Director/Qualified Professional #1 revealed: The local Department of Social Services (DSS) was in process of investigating an allegation of abuse involving Staff #8 choking Former Client

Former clients were allowed to play in each other's rooms until" ...[Former Client #4] started raping [Former Client #2] ...;"

From the state's report. Deficiency cited, complaint survey; Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint s. Cited: V 366; V 132; V 293.

Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.

Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Was brought into the library by Staff #4 when he attempted to elope and Staff #4 who grabbed his shirt and pushed him against the wall; [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van, Review on 10/2/19 of the North Carolina Incident Response Improvement System revealed:

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V132. "[...]" marks text left out between sentences.

In plain words: A client said a former staff member forced him to perform oral sex and sexually abused him on two dates after earlier inappropriate touching. The client told a staff member, who reported the abuse to a qualified professional and the program’s licensee. Our summary of the state's report. The state's own wording follows.

"[Client #2] further stated that he was forced to perform oral sex on [Former staff 11] on May 19, 2019 around 9 pm while at the facility. [Client #2] stated that [Former staff 11] stood up and told [client #2] to come over to where he was standing and grabbed his head and pulled his head down to his penis area." [...] He was sexually abused by [Former staff 11] on 5/17/19 and 5/19/19. Three to four weeks prior to 5/17/19 and 5/19/19 sexual assaults, [Former staff 11] had touched his butt "like four times before." [...] Denied that he ever told [Former staff 11] about his past or that he was sexually abused. [...] Client #2 made her aware that [Former staff 11] sexually abused him and she contacted the QP, the Licensee #1 and an unknown staff. [...] On 5/20/19 at approximately 12:27 a.m. he received a call from the QP that [Former staff 11] has allegedly sexually abused client #2. [...] And he said the guy eventually molested him.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

The MP had built a program for boys "that a [North Carolina (NC) law enforcement association] could model statewide;" [...] 2/12/17 Juvenile Petition: physically abused and injured or sexually abused by parents Interview on 6/25/18 with Client #1 revealed: [...] Staff #14 "had put him (Client #6) on the floor on his stomach because he started punching stuff and being violent;" [...] Staff #14 and Staff #13 told him he had no rights and then had slammed him on the floor trying to restrain him; [...] Staff #14 had left Client #2 at the "temple" or "mud dog"( public baseball field with concrete/rock stairs) to work out running up the stairs and around the ball field because Client #2 had said he was going to run away; [...] Staff #14 had worked for the local Sheriff's Department for 2 % years; [...] Staff #14 walked back to the client's room and Client #5 was kicking the bed and thumping the wall;

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 514. "[...]" marks text left out between sentences.