Severe reports

In plain words: A child in the program stole a school laptop from the office to contact men and then ran away from the group home. Staff found her, talked to her about the dangers of contacting older men, and she agreed to follow safety rules before running away later that shift. Our summary of the state's report. The state's own wording follows.

One elopement noted in September 2017. [...] Due to hospitalization between 03/06/18 and 03/21/18, client #8 was not able to be interviewed. [...] 02/25/18, client had been caught inappropriately using her alternative school laptop...client had stolen her school laptop from the staff's office and was attempting to utilize in her bedroom to facetime men...staff discovered Cc client using the laptop during a routine check and retained the tablet..staff educated the client on the dangers of seeking older men, giving out her personal information such as the residential placement's address and attempting to link up with men to be sexually active... client was able to contract for safety and agreed not to steal electronics, utilize face book again to contact men and to really focus on her school work...later in the shift, client eloped from the group home. [...] She was hospitalized in that area.

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

In plain words: The facility failed to ensure a doctor was told about an alleged physical abuse incident involving a patient. The facility also failed to ensure a doctor examined the patient within twelve hours as required. Our summary of the state's report. The state's own wording follows.

Based on review of facility documents, clinical record review and staff interview it was determined the facility failed to ensure the Program Manager or the Nursing Supervisor notified the Attending Physician of the allegation of physical abuse and the facility failed to ensure the Attending Physician or the Medical Director assessed Patient #1 within twelve (12) hours of the alleged physical abuse per facility policy. [...] The attending physician or the Medical Director may order that the patient be transferred to Charleston Area Medical Center for evaluation of physical or sexual abuse allegations." 2.

From the state's report. Deficiency cited, complaint survey. Cited: N 196 483.372(a) MEDICAL TREATMENT FOR INJURIES. "[...]" marks text left out between sentences.

Child # 1 starts to scratch his/her arm, and 47 seconds later Staff Member A initiates a restraint on Child #1. During the restraint Staff Member Ais seen slamming Child # 1’s face off of a table twice, dragging Child # 1 off of a Chair by his/her left arm, and tifting Child #1 in the air by the left arm, while Child # 1 is sitting on the floor.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.32.b.

Onor about February 8, 2023, the Program received a second complaint alleging a counselor (Stowe) employed at DYS Brush Prairie was arrested for having — a sexual relationship with Patient #10.

The notice explained that the Program would comply with the conditions in Part 2 to protect covered records and information obtained from DYS Brush Prairie. — The records request letter explained that the investigation had to do with allegations of staff sexual misconduct with patients and with a failure of facility systems to ensure patient safety.

Swope also engaged in nonconsensual sexual contact with Patient #11 during an outing from DYS Brush Prairie.

2023-2056) the Program became aware of allegations that another counselor at DYS Brush Prairie (Swope) had engaged in sexual contact with Patient #11 within — DYS Brush Prairie’s facility and while Patient #11 was admitted to DYS Brush —- — Prairie.

Further, Patient #9 reported to the Program and DYS Brush Prairie that the incidents — with Reinmuth resembled how they felt when they were raped by a teacher.

During this phone call, Patient #9 reported they had been in communication with Reinmuth since being discharged, and that Reinmuth had been communicating with another patient of DYS Brush Prairie outside of the facility. — Patient #9 reported the conduct of Reinmuth had triggered a manic episode due to past trauma when Patient #9 had been raped by a teacher.

While admitted to DYS Brush Prairie, Patient #9 had frequent contact — with Reinmuth, including disclosing to Reinmuth that Patient #9 was raped by a teacher.

From the state's report. Findings of fact, notice of intent.

Per interviews and the facility's documentation Resident #2 stated Ina safety concern meeting on HB. he/she wanted to "blow his/her bralns out or go shoot up a preschool." Staff Member B addressed thie statement by printing out and showing to Resident #2 a picture of deceased children, Resident #2 atated he/she fell traumatized by this experience,

From the state's report. Citation, iingident - _ inspection. Cited: 55 Pa. Code § 3800.32.n.

Staff Member A was observed on video shoving Child #1 inside the bedroom and closing the door several times behind them.

On Staff Member A was observed on Video Physically shoving another resident which caused the resident to fall and hurt their arm.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.53.b.

In plain words: A staff member and a child went into a room with the lights off after smoking. It is alleged the staff member had sexual intercourse with the child inside the room. Our summary of the state's report. The state's own wording follows.

Staff Member A and Child #1 reentered the bullding after Ihey were finished smoking, Staff Member A walked in to the private communily area room and Child #4 followed, Staff Member A and Child #1 wero inside the room for about four minutes wilh the lights off, Staff Member A had allaged sexual intercourse with Child #1 inside the private communily area room, The lights flickered brlefly before Staif Member A exited the room and Child #1 followed, 3.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b.

Based 6n child and staff interviews as well as video footage review and pictorial documentation of injuries, the investigation determined that Child #2 was involved in an improper restraint ona ith Staff Member B and Staff Member C.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.202.b.

ont Child # 1 received treatment at Sacred Heart ER for a head injury and forehead laceration stemming from a manual restraint Initiated by Staff Member A. Child #1 had a 1 cm linear laceration in a oblique placement in the center of his/her forehead, resulting from Child # 4 hitting his/her head off of a wall during the restraint.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

In plain words: A staff member punched a child in the face multiple times and cursed at them while multiple staff members held and carried the child. The facility also failed to report the assault to the department and contracting agency within twenty-four hours as required. Our summary of the state's report. The state's own wording follows.

Child #1 was restrained and physically escorted by Staff members A, 8, C, D, E, F, G, H, During (he escort, Staff person A was observed punching Child #4 In the face multiple (Imes and repeatedly told Child #4 to “shut the {_k up.” Stalf person A Was also observed on a video of the event continulng fo punch Ihe chitd in the face while the child was carted dovm the hallway by Stalf members B, 0,D,€,F,G,H In a continual restraint, Child #4 sustalned mutiple tnfurles as a result of the ascault by StaffA. [...] Tho Spectal Victlms Unit was contacted and résponded by assigning a detective (Datectiva Danlel OMalley #895} tothe case.

On BE chiia #1 was assaulted by Staff A. ‘The facllly failed lo complete a written reportable incident report on a form prescribed by the Department; send it_fo the approprlate Departmental office and contracting agency within 24 hours. —

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.18.c. "[...]" marks text left out between sentences.

Child: #1 was physically assaulted by Child #2 several times, which resulted in substantial-bruising on Child #1.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

Child #7 was sexually abused by Child #5 Tl Child #5 took Child # 7's hand:and put it on Child # 5's private area without consent. ;

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

Furthermore, thel child paychiatic evaluation reeds: “Recently [the child] had cut severe enough that fhe/she] required 27 sutures, [The child] reports [he/she] last cut. [...] The child then swallowed the razor blade. According to notes taken by Staff Member 8, the facility's contractad peychiatriat, Child #1 swallowed the blade because “wea hoping H would kill (hinvher].” The faoilty’s internal policy prohiblis penci] sharpeners In the posseasion of childran or present In the facility at any tins. ‘The factity developed an initial written safely plan on fEEEEhch indicated that Child #1 “will be encouraged to utilize [molding clay, lying down, coloring and humor] to cope with negative feelings.” This written safety plan was not developed with methods fo monitor and prevent self-harm, increased general supervision, or othar adequate methods to ensure child safety.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

In plain words: A child in the program told a staff member about thoughts of self-harm, but the facility did not immediately increase supervision. Later that evening, the child attempted an act of self-harm, and the home then increased supervision. Our summary of the state's report. The state's own wording follows.

" Risk: Miiig#has reported suicidal ideation thalglipouchts to self harm Plan: The Therapist processed coping skills thatllll—has readily available and revised lllMeafety pro! ort Min manag M@@B safety. [...] According to Staff Member A's notes from that session, Child #1 Indicated “continued thoughts of self-harm’. During an interview with representatives of the department, Child #1 also expressed that he/she “had urges and flashbacks and wanted to i wrap sheet around neck"on and also stated that he/she expressed this to Staff Member A during the 15 therapeutic i interaction, ‘The facility did not Immediately implement intensive supervision as part of their intemal safety plan procedure protocol. i At6:14 pm or Chitd #1 attempted an act of self-harm. [...] At 9:10 pm the home implemented Increased supervision due to suicidal ideation and self-harm.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

During restraint on 08/02/2016 at 7:10 AM, Staff Member B used his/her back leg to push Child # 1's head and chest forward to Child #1's knees, while Child # 1 was sitting with his/her legs out on the floor, causing pressure and weight on Chitd # 1's respiratory system.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.211.b.

On 07/17/2016 during a restraint, Staff Member A used his/her leg to push into the back of Child #1, while pulling Child #1's arms behind him/her, causing pain in Child # 1's shoulder.

on 07/17/2016 during a restraint, Staff Member A used hissher leg to push into the back of Child #1 while pulling the arms of Child #1 behind hinvher in an effort to make Child #1 apologize to resident staif.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.202.a.

Between February and March of 2016, Child #1 was twice subjected to sexual abuse by Child #2 and Child #3. The instances of sexual abuse occurred in the bedroom shared by Child #1 and Child #3. Child #2 forced Child #1 fo perform oral sex on Child #2 and Child #3 by threatening Child #1 with bodily harm if he/she did not comply. [...] Interviews with children confirmed that the assault was in retaliation for the sexual assault referenced above. [...] Staff Member A told the children "you know what needs to be done", and "you know what needs to happen.” Staff Member A was told by one of the children "go to your room” while the assault happened.

On Saturday April 2, 2016, Child #1 disclosed to Staff member A that a sexual assault was perpetrated on him/her by Child #2 and Child #3.

Staff Member A was aware of the physical assault on the date it occurred.

From the state's report. Citation, renewal inspection, licence action taken. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.15.a; 55 Pa. Code § 3800.16.c. "[...]" marks text left out between sentences.

On Saturday April 2, 2016, Staff Member A did not provide adequate supervision to Child #6, Child #8 and Child #9 who absconded from the program and entered the upstairs program, at approximately 11:00 PM, where they participated along with children from the upstairs program in a physical assault on Child #2 and Child #3.

From the state's report. Citation, renewal inspection, licence action taken. Cited: 55 Pa. Code § 3800.55.f.

In plain words: One staff member kicked a child in the behind. Another staff member pressed their forearm into the back of a second child's neck. A third staff member threw, pushed, and knocked a third child into a quiet room. Our summary of the state's report. The state's own wording follows.

Slaff Member A let go of Child #1 and when Child #4 got up and altempted to leave the room Staff Member A kicked Child #1 In the behind. [...] Staff Member B came up behind Child #2 and placed thelr forearm into the back of the neck of Child #2 and pressed their weight onto the back of Child #2, On 1/11/2016, Slaff Member C and Child #3 were In the qutet room, Child #3 altempted to leave the quiet room and Staff Member C picked up and threw Child #3 back Into the quite room. Staff Member C also pushed Child #3 Into the wall and onto the ground while attempting to keep her In the quiet room.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b. "[...]" marks text left out between sentences.

In plain words: A staff member restrained a child, causing a circular abrasion on the forehead, abrasions on the cheek, a reddened area under the eye, neck scratches and abrasions, and a large abrasion with petechiae on the right shoulder blade. Our summary of the state's report. The state's own wording follows.

According to the facility's documentation, the restraint resulted in Child # 1 sustaining an abrasion at the midline of his/her forehead, a 2cm circular abrasion and a 4cm linear abrasion to the left cheek, a sialt redenned area under the left eye, two 2cm abrasions to the loft side of his/her neck, a linear scratch to the midline of hisMer neck, and a 3 inch abrasion with petechiae surrounding the area on his/her right shoulder blade and 2 linear abrasions,

According to tho facilily's documentatlon, the restraint resulted in Child ## 1 sustaining an abrasion al the midline of his/her forehead, a 20m circular abrasion and a dem linear abrasion to the left cheek, a small sedenned area under the left aye, {wo 2cm abrasions to the left side of his/her neck, a linear scratch to the midline of hisfhor neck, and @ 3 inch abrasion with petechiae surrounding the area on his/her right shoulder blade and 2 linear abraslons.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.202.b.

On 3/6/2016, Resident #3 self-harmed with a piece of glass he/she reported to have found near the back doors of hallway A of the _ Expressions unit, Resident #3 was sent (o Ohio Vailey Hospital via ambulance where heishe was ‘reated wilh medical glue for an Injury to hisfhes left arm,

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.87.a.

In plain words: A staff member physically held a child to the floor of a bedroom after the child yelled and got close to the staff member. The child complained of arm pain afterward, went to the hospital, and was diagnosed with a broken arm. Our summary of the state's report. The state's own wording follows.

On 7/6/15 al approximately 8:30 AM, Staff Member A manually restrained Resident # 4 {o the floor In a resident bedroom for yalling and getting Into the face of the staff member, Following the restraint, Resident # 4 complained of left arm discomfort and was transported to a hospital emergency room and was diagnosed wilh a radial shaft fracture to his/her left arm.

From the state's report. Citation, complaint, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

Realdent # 8 had a safely plan dated 6/16/16 thal was created In fasponse {9 being found In the shower room on 6/16/18 with Resident # 10 , and the residents reportad to staff thal thay engaged In Klesing, unclolhed touching, and oral sex, The safely plan Indicated that there will be a ive fool rute' with Resldant # 8 and Resident # 10, that they will nol be permilted to be on the same hallway as each other, and {hat they are not lo be permitted to leave the hallway unsupervised, While Resident #10 was showering on 8/6/16 at approximately 7:00 PM, Stalf Member B was monitoring the showers from the hallway and left hlsfher hatlway position to answer (he telephone al the slaff desk.

From the state's report. Citation, renewal, complaint, incident inspection. Cited: 55 Pa. Code § 3800.142.

In plain words: A sixteen-year-old resident sexually assaulted an eleven-year-old resident in their shared bedroom. A staff member later took the younger resident to the hospital, and the older resident was charged with rape and other crimes. Our summary of the state's report. The state's own wording follows.

On 8/7/15 al approximately 2:30 PM, Staff Member B transported Resident #2 to a hospital's emergency room due to the resident belng sexually assaulted by Resident #1 on the evening of 8/6/16, The jocal police department responded {o the hospital at approximately 3:68 PM to investigate (he sexual assault.

On the evening of 8/6/15, Resident #1, a 16 year-old, sexually assavited Resident #2, an 11 year-old, in the residents' shared bedroom #4, Ag a fesullt of the Incident on 8/6/15, Residen! #1 was charged with rape, Involuntary deviate sexual assaull, stalutory sexual assault, aggravated indecent assault, ‘and indecent assault, . [...] Immediate Action: At approximately 12:35 pm on August 7, 2015 Staff B approached Director EEE to inform her that resident 2 had reported 1o SB that he had been sexually assaulted during the previous night (8/6/15). [...] At approximately 1:15 pm, Director HE otified BCCYS regarding the incid ied to [Resident 2]'s agency, Butler County CYS, that he had been transported to the ER,.

Resident #1's-heallh and safely assessment dated 6/6/15 indicates, "Any concems of the child being a perpetrator of sexual abuse? [...] Whiie not within any staff person's eyesight on the evening of 8/6/15, Resident #1, a 16 year-old, sexually assaulted Resident #2, an 11 year-otd, in the residents‘ shared bedioom #4. As a resull of the Incldent on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assault, statutory sexual assaull, aggravated indecent assault, and indecent assault,

Resident #1's health and safety assessment daled 6/5/15 indicates, "Any concerns of the child.being a perpetrator of sexual abuse? [...] While not within any staff person's eyesight on the evening of 8/5/15, Resident #1, a 18 year-old, sexually assaulted Resident #2, an 11 year-old, In the residents! shared bedroom #4, As a result of the incident on 8/6/15, Resident #1 was charged with rape, involuntary deviate sexual assaull, statutory sexual assault, aggravated indecent assault, and indecent assault, “ .

A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment, On the eveniig of 8/6/16, Resident #1, a 18 year-old, sexually assaulled Resident #2, an 11 year-old, in the residents’ shared bedroom erere 4 harged with rapa, Involuntary deviate sexual assault, statutory sexual ee a monitoring process will be documented for each child, Repeat Violation: No

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.16.c; 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.142; 55 Pa. Code § 3800.32.b. "[...]" 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 wrote inappropriate entries in a childs journal, including vulgar profanity and statements denying rumors of sexual abuse involving other children in the program. Our summary of the state's report. The state's own wording follows.

On or around the months of July 2015 and August 2016, staff member A wrote mulliple Inappropriate entries in residant#3's journal, Including stataments that used vulgar profanily and addressed multiple allegations of sexual abuse betwoen staff momber A and resident #2 and resident #1, The journals Indicated the following statements and question: "Yas they are rumors, | did not touch her or (resident #1] In any way shape or form. | can't belleve you told them to rat or have omeone olse rat?" Is crazy, | can't work here any longer, | can't belleve you. { would lose my Job over this ass.” eli | wasn't being smart and I'm not a fraud, [resident #3) now your hurting my feelings."

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b.

Child #1 eloped around 8:35pm and was hit by a train shortly after, resulting in the death of Child #1.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.55.a.

In plain words: A staff member dragged a child along a gravel pathway by one arm. The child was evaluated the next day, and a nurse documented a purple bruise on the left shin and a red scratch on the back. Our summary of the state's report. The state's own wording follows.

On 4/12/2016 at approximately 7:30 P.M., While returning to the van from a Ip to a park, Staff Member A dragged Resident H along a gravel pathway by one of Resident /#1's arms for approximately 10 feel, Resident #1 was on hisMer knees and ended up on his/her back while belng dragged, As a result, on 4/13/2016 af approximately 11:04 A.M., Restdent #1 was evaluated by a lloensed practloal nurse and the following Injurlos wore documented, “pusple brulso on left shin and rod soratch on loft site of back.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.h.

8/346, Child #2 passed away, The facilitydid-fot:tiake’an oral Feport to the appropriate: Departmental regional office within 42 hours. : .

From the state's report. Citation, onsite ‘inspections dates and. department representatives on inspection, licence action taken. Cited: 55 Pa. Code § 3800.16.d.

On 3/6/2015, Resident #3 self-harmed with a piece of glass he/she reported to have found near the back doors of hallway A of the Expressions unil, Resident #3 was sent to Ohio Valley Hospital via ambulance where he/she was {reated with medicat glue for an Injury to his/her left arm.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.87.a.

Staff Member D arrived to the residence at approximately 7:04 PM, with scissors, and Child #1 was able to be freed from the door, Child #1 died as a result of hanging and was pronounced dead at 7:38PM.

At 6:57 PM, Staff Member A instructed Staff Member B, to contact the carpus Registered Nurse, and Staff Member C to find something sharp to free the ligature from around Child #1's neck, Staff Member C searched the kitchen drawers for a sharp utensil, but could not locate anything at that time. [...] Staff Member D was informed that Child#1 had hanged himself, and that she needed to bring scissors to the facility immediately.

From the state's report. Citation, incident ; inspection, licence action taken. Cited: 55 Pa. Code § 3800.96; 55 Pa. Code § 3800.32.b. "[...]" marks text left out between sentences.

Clients on high supervision must be in direct Vew of tho assigned statt af ai times.” The facility's Observation Record indicated the “ctlont nas had extersive recont inpatient hospitalization, sign‘ficant for suicidal ideutiowplan, saif-harm, and audilury dalfucinallons, Dr. ordered to place client on Hiyh Supervision, af 1:64 PM, as a precaution sue to uncarfamty of ckent's baseline.” On 12/5/14 al approximately 8:30 ?M in Resident ¥ 1's bedioum. Resident # 1 reported to Stall Member A that he/she fell unsate and had Just attempted to self-harm by scratching his/her left wrist Staff Member A lefl Ihe resident's bedroom to notify the medical department and asked Staff Member 8 lo moaitor the resident.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.142.

On 08/04/14, Resident #1 and Resident #2 each ingested multiple tablets of the medications that were obtained by Resident #1 on 8/03/14. This resulted In Resident #1 being taken to the local hospital by facility staff persons and then being transferred by medical helicopter to the regional nospital to receive inpatient treatment, and Resident #2 being taken to the local hospital by facility alatf pereons {o receive oulpalignt treatment on 8/04/14.

From the state's report. Citation, complaint inspection.

To release Child #1's grip, Staff Member A bit Child #1 resulting in 2 bite marks to his/her fight forearm.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

Shorily prior to discharge on 2/18/14 Child # 2 was picked up and slammed by Staff Member A onto the floor of hishher bedroom resulting in the child's lip bleeding.

Shortly prior to discharge on 2/18/14 Child # 2 was picked up and slammed by Staff Member A onto ihe floor of hishher bedroom resulting In the child's tip bleeding.

From the state's report. Citation, complaint, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

The resident's letter read, “They are trying to pin you for the 2 girls rape thing, But [name] is talking to them so am 1.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.32.g.3.

In plain words: A staff member sexually exploited a child by discussing sexual acts on social media. Our summary of the state's report. The state's own wording follows.

Staff Person A was employed by the legal entity at a Chapter 3800 licensed facility located on the sama property as Claney House ITU, Staff Person A was hired on 10/18/13 and was terminated on 01/29/14, On 01/28/14, Staff Person A sexually exploited Child #1 by engaging in conversations on a social media web} I where he/she discussed doing sexual acts to the child and having the chitd do sexual acts to himvher. :

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

On 3/16/2014 at 6:30pm Staff member A witnessed Staff member 8 kick Child 4 in the leg causing the child to fall to the ground, Staff member A stated that Staff member B, who was Child 1's 1:1 at ihe time, kicked the child.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.205.b.

On 02/06/14 at approximately 11:15 a.m., Staff Person A grabbed Child #1 by the collar of hand on the child's back, Staff Person A pushed Child #7 down the stairs resulting in the C, who was on the second floor landing of the staircase, and Staff Person B, who was on witnessed the incident.

Staff Person A grabbed Chitd #1 by the collar of his/her sweatshirt, and with one hand on the collar of the child's sweatshirt and one hand on the child's back, Staff Person A pushed Child #1 down the stairs resulting in the child falling on his/her buttocks. On 02/08/14 at approximately 11:50 a.m., Staff Person A used one hand to push Chitd #1 out of the chair of the kitchen table onto the floor causing the child to hit hishhar haad off of a metal heater.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.15.a; 55 Pa. Code § 3800.32.b.

Child # 1 was the victim of an indicated case of physical abuse in an assault by Staff Member A that caused Child # 1 to be hospitalized,

From the state's report. Citation, j ‘type of inspection: partial bha docket number: notice: un inspection. Cited: 55 Pa. Code § 3800.32.b.

Child 1 has a history sexually acling out and had allegedly sexually assaulted a peer at another facllily prior to being admitted on 6/30/12.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.142.

Child 4 eloped from the presence of his/her 7:1 staff member as the child exited the facility's vehicte following the transport to the child's school, Child 4 ran into the wooded area next to the school, The child's 1:1 staff member and 3 other staff members pursued the child. [...] Staff Member A was then removed from the restraint and separated from the child, The restraint technique utilized by Staff Member A was an Inappropriate restraint that was not within the scope of the restraint {raining that Staff Member A received on 5/30/2043.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.208.b. "[...]" marks text left out between sentences.

On 10/24/13, Resident #1 documented on the facility's “Client Physical Intervention/&mergency Restrictive Procedure Form’ that Staff Peraon A “glammed me on my stomach to the floor then to the wall,” and that as a result Resident #1 experienced inability to fee! fatal movement, cramping, upper thigh paln, and swollenness in ankte.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.15.a.

In plain words: During a physical hold, a staff member pressed an elbow against a child's throat and made it hard for the child to breathe. The child was left with scrapes and needed an inhaler after the incident. Our summary of the state's report. The state's own wording follows.

Duzing the manual restraint, Staff Person A had his/her elbow pressed against Resident #1’s throat, which applied pressure to the resident's respiratory system and restricted the resident's breathing, A physical evaluation form, dated 10/27/13 at 6:25 p.m., indicated Resident #1 had abrasions on the right front of the neck, abrasions on the right collar bons, abrasions on the right shoulder, and that the resident required administration of Ventolin, an inhaler, following the manual restraint.

From the state's report. Citation, interim, incident inspection. Cited: 55 Pa. Code § 3800.32.b.

On 7/5/13 Resident 1, attempted suicide by placing their belt around thelr neck and climbing into a closet. [...] The following day, 7/7/13, Resident 1 placed their belt around their neck in an attempt to commit suicide. [...] Resident 1’s safety plan was not updated for this Incident, On 10/12/13 Resident 2, date of admission 3/18/13. attempted to hang themselves by the neck with thelr belt, An updated Heaith and Safely assessment was completed for Resident 2 on TOMAS: not within a 24-hour perlod.

From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

An allegation of sexual abuse involving Resident #1 and Resident #2 was reported to staff persons al approximately 40:30 p.m. on -|-03/19/43,-and-the-facility-did-not- report the allegation-to-ChildLing until 9:48 a.m. on 03/20/13. —— =

On 03/19/13 Staff Person A did not conduct observational checks of Resident #1 and Resident #2 from 9:46 p.m. through 10:06 p.m. and from 10:08 p.m. through 10:33 p.m. On 03/18/13 between 9:30 p.m. and 10:30 p.m, Resident #1 was sexually assaulted by Resident #2 in the residents’ shared bedroom.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.15.a; 55 Pa. Code § 3800.32.b.

Staff Member B sexually abused Child #3 and #4. ssi?

From the state's report. Citation, renewal inspection. Cited: 55 Pa. Code § 3800.32.b.

On 9/18/12, Child 1 was held face down on the floor during a prohibited manual restraint by Staff Member A, Child 1 received a laceration to the chin during the restraint process.

From the state's report. Citation. Cited: 55 Pa. Code § 3800.21.

(b) Review of the medical record for Consumer #1 revealed a swallowing evaluation was completed on 06/16/04. This swallowing evaluation revealed the following: "There was frank laryngeal penetration and tracheal aspiration upon ingestion of thin and thick liquid and puree material. [...] Theses issues were identified as needs as early as 03/13/06, almost one (1) year prior to the death of the consumer.

(xi) On 2/12/07 at approximately 12:30 p.m., while at the day program, Consumer #1, aspirated a piece of hot dog and died.

These issues were identified as needs as early as 03/13/06, almost one (1) year prior to the death of the consumer.

From the state's report. Deficiency cited, complaint survey. Cited: C 242 64-11-7.3.c. Treatment Plan; C 123 64-11-5.5.b.4. Center Responsibility; C 240 64-11-7.3.a. Treatment Plan. "[...]" marks text left out between sentences.

Bipolar, ODD, ADHD, Schizophrenia, Substance abuse, and physical sexual abuse.

From the state's report. Deficiency cited, survey. Cited: C 119 64-11-5.5.a. Center Responsibility.

Findings include: (a) Consumer #7 alleged on 6/15/01 that Staff A had sexually abused the consumer by the staff grabbing his crotch on three (3) separate occasions. [...] (b) On 8/23/01, the Center reported to the State IIU that Consumer #5, #6 and #3 alleged that they had been improperly restrained by Staff B and had sustained injuries as a result, over a two (2) week period of time. [...] (c) On 11/28/00, Consumer #8 alleged that Staff C dragged him across a room, pulled his arm and pushed the consumer into a chair two (2) weeks earlier.

From the state's report. Deficiency cited, survey. Cited: C 359 64-11-8.2.b. Violation of Consumer Rights. "[...]" marks text left out between sentences.