The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.
A child in care was improperly restrained.
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
In plain words: State officials found allegations substantiated that a staff member physically abused children, gave medicine early, and disrupted sleep. Videos also showed the staff member hitting and kicking children while two other staff members watched without stopping it. Our summary of the state's report. The state's own wording follows.
On March 17, 2021, Community Care Licensing (CCL) received an allegation of Staff (Staff #1 are assaulting clients (Child #1 and Child #2 in care. [...] Confidential interviews report a second video of the incident was obtained and confirmed the assault including [Staff 1] hitting [Child 1] and [Child 2] several times before throwing them to the floor. Record review revealed additional observations of both videos noted [Staff 1] was seen to have been kicking both [Child 1] and [Child 2] as they were lying on the ground. [...] Record review revealed observations of the two videos obtained of the incident show [Staff 2] and [Staff 3] were present during the assault and did not interject or try to stop the fight.
On December 11, 2020, Community Care Licensing (CCL) received an allegation of facility staff (Staff #1 A copy of the report was discussed and provided along with appeal rights to Childhelp Merv Griffin Quality Assurance Coordinator, Marlo Felix. physically abused child (Child #1 in care. [...] Based on confidential interviews, observation, and record review of facility documentation, the allegations facility staff (Staff #1 physically abused child (Child #1 in care, Staff (Staff #1 administered medication before the designated time, and Staff (Staff #1 interfered with client's (Child #1, Child #2, Child #3, Child #4, Child #5, Child # 6 ([Child 6]), Child #7 Child #8, Child #9, Child #10, ([Child 10]), Child #11, and Child #12) nightly sleeping arrangements are substantiated.
From the state's report. Substantiated. Cited: 87072(d)(11). "[...]" 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.
While unsupervised the child in care engaged in inappropriate sexual contact with an adult in care.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
Video footage provided shows a staff member placed a child in an inappropriate restraint.
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
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.
On December 27, 2020, CCLD received a complaint referral alleging Neglect / Lack of Supervision as Child #1 reportedly had access to hazardous items and [Child 1] ingested hazardous items while in care (see Confidential Names form LIC811, dated 5/28/2021). Information obtained during the investigation including interviews and review of related medical records for [Child 1] indicates in part, numerous hospitalization's for [Child 1] due to ingesting foreign objects and being placed on involuntary psychiatric holds between August 2020 and February 2021. [Child 1] was hospitalized on 12/14/2020, for "foreign body ingestion" of glass. Records indicate [Child 1] ingested two fistfuls of glass shards. On 08/31/2020, [Child 1] was admitted to the hospital emergency room with complaint of swallowing glass and ingesting a metallic screw seen on x-ray. [...] On 10/04/2020, [Child 1] was admitted to the emergency room for ingesting window screws.
From the state's report. Substantiated. "[...]" 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.
A staff member had inappropriate relationships with children in care.
From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
Staff threw a water bottle and struck resident in the face.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
Staff grabbed a resident forcefully causing the resident to fall forward into a window, with his face pressed into a mat.
A staff inappropriately restrained a 16 year old resident, resulting in an injury to the head.
From the state's report. Risk level: High. Cited: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
In plain words: State officials received a report that a lack of supervision allowed a child in the program to engage in sexual activities with an unknown adult male at the facility. A staff member stated she assumed the child just preferred staying alone in her room instead of socializing. Our summary of the state's report. The state's own wording follows.
On March 31, 2020, Community Care Licensing received claims alleging a lack of supervision contributed to Client #1 engaging in sexual activities with an unidentified male while in the facility. [...] [Staff 1] disclosed that she was under the assumption of knowing [Child 1] "having the habit of staying in the room and not socializing with the residents in the living room." [Staff 1] discovered the unidentified male was present at the facility when a neighbor witnessed the male jump the fence, after the (Continued on LIC9099-C) Los Angeles Sheriff Department (LAPD) arrived at the facility and began questioning staff and residents about the alleged incident.
From the state's report. Substantiated. "[...]" 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 February 3, 2021, Community Care Licensing (CCL) received a complaint alleging facility staff inappropriately restrain minors and demonstrate inappropriate forms of discipline towards clients in care. [...] Regarding the allegation of Staff #1 inappropriately restraining minors, confidential interviews revealed [Staff 1] restrains children by twisting their hand(s) and pulling the children's hand(s) behind their lower back. [...] Based on interviews and records review, there is a preponderance of the evidence to prove Staff #1 inappropriately restrained minors (Child #2, Child #3, Child #4, Child #5) and facility staff demonstrate an inappropriate form of discipline by placing children in a group meeting for extended periods of time until children confess to the feces on the restroom walls.
From the state's report. Substantiated. "[...]" 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.
A staff member shoved a resident in between restraints.
From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.
On December 14, 2020, Community Care Licensing received claims alleging a lack of supervision resulting in inappropriate sexual contact between clients as it was reported that Client #2 was a victim of sexual assault by Client #1 while in the facility. [...] Information revealed [Child 2] was the victim of sexual assault from [Child 1]. [Child 2] was reportedly scared of [Child 1] and [Child 1] forced [Child 2] to engage in sexual acts.
From the state's report. Substantiated. "[...]" 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.
Child #1 spit at Staff Member A and the staff slapped the resident in the face.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32 Specific Rights.
A caregiver engaged in a discussion with children in care about the caregivers personal sexual activities and preferences.
From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
Staff pushed resident down on the ground, causing bruising.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
Staff struck child in the face with her fist.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A child in care was subjected to physical abuse by a operation staff member.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A caregiver used excessive force during a restraint, causing substantial physical injury to a child.
From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
A staff dragged a child across the floor by gripping his ankles one with each hand and pulled the child.
It was reported that a staff conducted an improper restraint.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child.
Administrator was aware of on-going inappropriate relationship between a staff member at the operation and a child in care.
A caregiver who was on a safety plan due to an inappropriate relationship with a child in care allowed the child to stay at their home while still employed at the operation.
From the state's report. Risk level: Medium High. Cited: 748.535(2)(H) - Child-care administrator responsibilities-Ensuring persons whose behavior or health status presents danger to children are not allowed at operation; 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.
Staff were aware of allegations made by child in care regarding alleged inappropriate touching from a staff member.
From the state's report. Risk level: Medium High. Cited: 748.303(a)(3)(A) - Serious Incident-Report to Licensing as soon as aware of allegations or indications of abuse, neglect, or exploitation of a child.
It was reported consistently and verified on video review that Staff 1 hit Youth A in the face with the back of his hand. [...] DCWL considers all acts of physical discipline under corporal punishment, regardless of the intention to cause pain/injury.
From the state's report. Violation established, special investigation. Cited: R 400.10169 Discipline. "[...]" marks text left out between sentences.
The staff person slammed child #1's head into a wall, threw the child to the ground, and threw a citizen band radio at the child with significant force.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.205 Staff Training.
Staff 2 stated he pushed Youth A into her room and is seen in video footage pushing Youth A into her bedroom.
From the state's report. Violation established, special investigation. Cited: R 400.10103 Program statement.
Staff member A also kicked a table which resulted in hitting child number 1 in the chest.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights.
During an incident that occurred on 11/25/2020, Staff Member A punched Child #1 in the leg multiple times during a restraint. [...] During an incident that occurred on 11/25/2020, Staff Member B punched Child #1 in the face multiple times.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32 Specific Rights. "[...]" marks text left out between sentences.
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 intervened and resident then began slapping, punching, and kicking at staff when redirecting resident out from under the peer's bed.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 126 PROTECTION OF RESIDENTS N 126.
"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.
Per interviews with children, staff A and B who were in the home at the time were aware that child was struck in the head.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.k Specific Rights.
In plain words: A child in the program reported that another child grabbed her left breast while she was in a facility van and later grabbed her crotch at a YMCA pool. Our summary of the state's report. The state's own wording follows.
Critical Incidents/ as appropriate state body overseemg that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervismg below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ withm one busmess day any Critical below) or as otherwise specified m the will report to the Department of Health Healthcare s premises/ of any individual of receiving notice of the individuaFs https://fortress.wa.gov/doh/opu'do/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that involve serious or undesirable inpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forti'ess.wa.gov/doh/opmio/s?s=ComplamtFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee in an Assisted Living resident s physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.
1.Review of police report, titled “Supplemental Narrative”, dated 10/23/19, showed that Patient #1 reported sexual assault and harassment to the police. “TPatient #1] confirmed that there have been several incidents and |] asked [Patient #1]to tell me [Police Detective] about the first time that something happened. [Patient #1] told me they were in a facility van coming back from an outing...[Patient #2] reached through a ‘crease’ in the and he grabbed van the left side of her body, under her shirt... [Patient #1] told me [Patient #2}] grabbed her left breast when he reached through her shirt’.” “I [Police Officer] told [Patient #1] | heard about something happening at the YMCA pool... [Patient#1] told me that she was swimming back and forth and [Patient #2] grabbed her crotch...[Patient #2] placed his hand down the back of her pants and then got out of the pool...” 2.
From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-1126(l)(b) Mentai health inpatient services - Policies and procedures "Adult.; WAC 246-341-1126(1}(b) Metal health inpatient services Policies and procedures Adult..
Critical h-icidents/ as appropriate state body overseeing that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervising below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ within one business day any Critical below) or as otherwise specified in the will report to the Department of Health Healfchcare s premises/ of any mdividual of receiving notice of the individuals https://forti'ess.wa.gov/doh/opuTio/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that mvolve serious or undesirable mpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forh'ess.wa.gov/doh/opuuo/s?s=Con'iplaintFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee m ai\ Assisted Living resident's physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.
From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075(2)(a) Resident Rights..
The findings of this investigation indicate that Staff 1 engaged in a physical altercation/corporal punishment with Youth A in violation of the facility’s discipline policies and this rule.
From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.
The findings of this investigation substantiate that Staff 1 implemented an improper restraint of Youth A by restraining Youth A in a prone position.
From the state's report. Violation established, special investigation. Cited: R 400.4157 Behavior management.
In plain words: The state substantiated a complaint that the facility failed to prevent an injury during a physical restraint. A staff member stated that a nurse failed to have a registered nurse check the injury and did not report it until the next day. Our summary of the state's report. The state's own wording follows.
Complaint #AR00023871 was substantiated, all or in part, with these findings Based on record review and interview the facility Cc 041115 oo 12/10/2019 failed to ensure an injury did not occur during the use of a physical restraint for 1 (Residet #1) of 1 sampled resident who was physically restrained. [...] She stated, "The nurse that was on duty did not get the RN [Registered Nurse] to do a face-to-face and didn't report the injury until the next day..." CFR(s): 483.362(a) Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and Cc the safe use of restraint throughout the duration of the emergency safety intervention.
From the state's report. Deficiency cited, complaint survey. Cited: N145.. "[...]" marks text left out between sentences.
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.
My therapist was in the hall and called for help. [PT #1] came and put me in a restraint." She was asked, "Did you get injured during the restraint?" She stated, "No." She was asked, "Who was present when this incident occurred?" She stated, "I don't think anyone saw the whole thing, cause she [PT #}) told them to get out of the room." c.
From the state's report. Deficiency cited, complaint survey.
On 10/16/2079, child 1 was subjected to mistreatment/corporal punishment by staff member A during an incident at the facility.
From the state's report. Citation, complaint inspection.
In plain words: Video footage showed a staff member pushing one child into a room and blocking the door with a chair. The staff member also pulled another child by the shirt and blocked a third child, causing that child to fall. Finally, the staff member dragged the first child by the ankle across the floor. Our summary of the state's report. The state's own wording follows.
Per video surveillance footage review, Staff Member A is scon pushing Child # 1 into his/her coom and placing a large wooden chair In front of Child # {'s door and sits in the chair, which is blocking Child # 1 from exiting the room. [...] Regulation- 3800.32(b)- A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment morning of 10/20/19, Staff Member A is seen pushing Child #1 into his bedroom, pulls Child #2 backwards by his shirt while the Child #2 is attempting to walk down the hallway, and is physically blocking Child #3 from walking down the hallway which makes Child #3 fall to the floor. [...] Child #1 falls to the floor and Staff Member A grabs Child #1’s foot/ankle and picks his leg up, Staff Member A takes a couple of steps while holding Child#1’s foot/ankle and drags Child#1 on the floor for approximately 2-3 feet.
From the state's report. Citation. "[...]" marks text left out between sentences.
Resident was throwing cups on the unit which upset one of his peer to where resident tried to fight the peer but staff intervene and got hit by resident. [...] Resident began to hit and kick staff spitting and scratching at staff when they blocked his blows, kicking in restraint repeatedly. [...] Resident attacked peers and staff, punching, hitting and kicking. [...] Resident Behavior ... [Resident] fighting with staff in restraint, shoving, kicking, biting and scratching in restraint ..." This progress note was signed by the physician on 9/22/19 at 10:00 a.m. 7.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 131 PROTECTION OF RESIDENTS N 131. "[...]" 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.
(1719) [5:19 p.m.] pt being sent to ER [emergency room] for evaluation of pain to R shoulder..." d. [...] Then he started to try to count to ten and started to bite one of them and I told him don't bite, don't bite." RN #1 and LPN #1 were asked, "Was he fighting?" LPN #1 stated, "He was trying to come up with his body and his legs were coming out of the restraint, so just kinda wiggle wormed." RN #1 and LPN #1 were asked, "Is bruising normal during a restraint?" LPN #1 stated, "You can get some bruising right there in the crease [indicating crease between the junction of the upper arm and shoulder], that is pretty normal, but not to that extent." Both RN #1 and LPN #1] stated, "Not to that extent." RN #[ and LPN #1 were asked, "Was it caused by undo pressure on his shoulder?" LPN #1 stated, "Yeah, I never seen a restraint look like that." e.
From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
The resident was placed into a physical restraint in released from the physical restraint at 8:34 p.m. The form documented a physical assessment was completed by Registered Nurse (RN) #1 on 4/26/19 at 8:34 p.m. The assessment documented Resident #1 had an injury during restraints: "c/o [complained of] left knee pain-good ROM [range of motion] [no] swelling...
From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128.
The facility failed to meet the regulatory requirements for Protection of Residents at N128, as evidenced by the facility's failure to ensure Resident #1 was freé from injury during a restraint. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Client #1 was asked, "Were you injured during the restraint?" The client stated, "Yeah, there was a knot behind my ear... [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d.
From the state's report. Deficiency cited, complaint survey. "[...]" marks text left out between sentences.
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.
In plain words: Due to a failure to provide proper staffing and supervision, young people in the program were sexually abused and exploited by a van driver and another man from the community. Our summary of the state's report. The state's own wording follows.
An admission assessment dated 3/9/18 noting “was admitted from a crisis center, Full Scale 1Q of 92, victim of physical, sexual and emotional abuse, witnessed her father being shot and killed by the police, held client and her mom hostage in a standoff, situational drug related incidents such as seizures, mini strokes, panic attacks and blacking out, self-injurious behaviors (picks skin), prior inpatient and outpatient treatment, verbal altercations, issues with being disrespectful and not following rules, destroys property, got high off of Xanax and overdosed (took 21 pills), sniffing cleaning products, AWOL from previous placements, poly-substance abuse (marijuana, alcohol, methamphetamines, over the counter drugs, crack/cocaine, opiates, hallucinogens, barbiturates and inhalants)."
Because of the failure to provide appropriate staffing and supervision, clients were sexually abused and exploited by the Church van driver (CVD) and another non-staff adult male in the community.
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 295 27G .1703 Residential Tx. Child/Adol - Reg. for A; V 293.
Staff #3 had made sexual comments to him and also made sexual gestures.
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367| 27G .0604 Incident Reporting Requirements.
A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.