Severe reports

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.

Enhanced Civil Penalty package for a violation that is determined to have resulted in the death of a client was approved on 05/18/2026. Pursuant to the Enhanced Civil Penalty law, Health & Safety Code section 1548 (e)(3)(A) for the death of a client receiving care at a transitional housing placement provider the Department issues an immediate civil penalty of $7,500.00. [...] A copy of this report and a Civil Penalty Assessment - Death/Serious Bodily Injury/Physical Abuse (Form 421-D) was provided to the Administrator.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

The following was discussed: In November 6, 2024, the Facility had a serious incident that occurred, which subsequently resulted in the death of a youth in care. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately resulted in death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

This report is regarding the death of a 14-year-old male client ([Child 1]), which reportedly occurred on October 28, 2025 at the facility. [...] Upon arrival, the Paramedics took over care of [Child 1] and transported [Child 1] via ambulance to the hospital, while FM proceeded to the hospital as well. [...] Hospital medical staff, along with a hospital social worker, informed facility staff and the [Child 1]'s mother that resuscitation efforts were unsuccessful, and [Child 1] was pronounced deceased. [...] The facility administrator acknowledged that the client's death was not reported to Community Care Licensing as required. [...] During the Case Management incident inspection, the Department obtained information regarding the death of a client while in care at the facility.

From the state's report. Deficiency cited at inspection. "[...]" 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 purpose of this inspection was to deliver findings for a serious incident which had resulted in a client's death in November 2024. [...] It was not until approximately four hours after the incident that staff were aware of the youth's condition which ultimately had resulted in a client's death.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

Death of a resident; c.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4150 Incident reporting.

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..

The purpose of the visit was to conduct case management follow-up on reports received by Community Care Licensing (CCL) reporting the death of Client 1 [LIC Confidential Names List was provided to licensee]. On September 8, 2025, it was reported to CCL that on September 2, 2025, [Child 1] left the facility without permission and was subsequently struck by a SPRINTER train. It was further reported that the facility received a call from the San Diego County Medical Examiner's Office on September 3, 2025, at which time facility staff was notified of [Child 1]'s death.The facility notified the client's family and placing agency.

From the state's report. Deficiency cited at inspection. 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 07/16/2025 at 01: PM, Licensing Program Analyst (LPA) Connie Goldie, made an unannounced, subsequent visit for the purpose of closing out a Case Management, regarding an incident that was reported to the Department on 06/20/2025, involving the death of a client. [...] Additionally, LPA Goldie received a copy of [Child 2]'s statements made to law enforcement and the client's, [Child 1]'s complete file.

From the state's report. Deficiency cited at inspection. "[...]" 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.

At 4:12 AM, the patient was found unresponsive. [...] Staff called Emergency Medical Services (EMS), and they arrived around 2:50 AM. EMS took the patient’s vitals, and the patient refused to be transported to the ER. [...] Staff called 911 and administered Narcan to the patient. [...] The document showed that EMS responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital. [...] Law enforcement responded to the scene and investigated the incident.

Failure to monitor access and egress to the facility can result in a lack of oversight of the facility and poor patient outcomes, including death. [...] The document showed that Emergency Medical Services (EMS) responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-080 – Resident care services (2)(h)(i)(ii) The licensee must address serious illness, medical emergencies, or threat to life; WAC 246-337-075 – Resident rights (2)(g) Each resident has the right to have a safe and clean environment.. "[...]" marks text left out between sentences.

On Thursday, November 21st, 2024 at 9: AM, Licensing Program Analyst (LPA) Brittany Crass, made an unannounced, subsequent visit for the purpose of closing out a Case Management, regarding an incident that was reported to the Department on November 12th, 2024, involving the death of a client.

From the state's report. Deficiency cited at inspection.

In plain words: A report alleged that a staff member sexually abused a client at the facility by kissing him and touching his genitals over his clothing. The state issued a civil penalty to the program based on this finding of sexual abuse. Our summary of the state's report. The state's own wording follows.

On April 16, 2024, the Department received a complaint alleging a Blissful Living Group Home, Inc. (BLGHI) staff ([Staff 1]) (Reference Confidential Names form LIC811 dated 11/4/24) sexually abused a client in care. [...] A client alleged that while at her home, [Staff 1] sexually abused him by kissing him on the lips and fondling his genitals over his clothing. [...] Under Health and Safety Code (HSC) section 1548(f)(1)(F)(2), a violation the Department determines results in sexual abuse as defined in Section 11165.1 of the Penal Code to a child receiving care through a Short Term Residential Therapeutic Program (STRTP) there shall be a civil penalty of $2,500. [...] A copy of this report, Confidential Names form LIC811 dated 11/4/24, Appeal Rights and form LIC 421D(CRP) for a Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were given to the facility representative.

From the state's report. Deficiency cited at inspection. "[...]" 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.

During the incident, the provider failed to conduct physical in person 15 minute checks on the client and the client was later found unresponsive.

From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.

At the facility, the client was out of supervision of staff and was later found unresponsive.

From the state's report. Out of compliance, focus inspection. Cited: R380-80-6(1)(a)-(i) Client rights.

In plain words: The state found that the administrator failed to keep the required log of unauthorized absences for at least 12 months. The complaint stated that a resident ran away after a fight and later passed away, and that other residents also ran away after fights. Our summary of the state's report. The state's own wording follows.

Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. [...] The complaint alleged a resident (later identified as [Resident 2]) had an unauthorized absence and later passed away. [...] The email stated "[Resident 2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 7. [...] The text message stated "[Resident 3] fought another [resident] then ran away." 8. [...] The text message stated "[Resident 4] ran away at 8:00 am [sic] after fighting another resident." 9. The Compliance Officer requested to review the facility's written log of unauthorized absences.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the .... "[...]" 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.

As a result, [Child 1] was found unconscious from an overdose and later passed away. [...] As a result, [Child 1] suffered an overdose and loss of life while under the direct care of STRTP [Staff 4]. Pursuant to the Enhanced Civil Penalty law, the Health and Safety Code 1548 (e)(3) states a violation the Department determines "resulted in the death of a person receiving care through a short term residential therapeutic program" the Department will issue an immediate civil penalty of $7,500.00. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.

From the state's report. Deficiency cited at inspection. "[...]" 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 Penal Code Section 11165.6 defines child abuse or neglect as a physical injury or death inflicted by other than accidental means upon a child by another person. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the Facility Director.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" 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] was transported to the hospital by ambulance from the facility with confusion and shortness of breath. [...] [Child 1]'s condition continued to de-escalate over time and on March 1, 2023, [Child 1] succumbed to death due to medical complications. During the week proceeding [Child 1]'s hospitalization, [Child 1] had been observed exhibiting symptoms of not feeling well while at school. Documentary evidence determined that [Child 1] died from illnesses that were contracted while in the care of the facility. [...] The Department has determined substantiated findings that staff did not provide medical attention in a timely manner contributed to [Child 1]'s death. [...] A copy of this report, Appeal Rights, and form UC 421-D(CRP) Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse was provided to Facility Representative during this visit.

From the state's report. Substantiated. Cited: 84078(b), 84064(f)(4). "[...]" 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.

Caregivers were unaware that a child in care, who had history of suicidal gestures, went into the restroom until the door was opened for another child. The child was found unresponsive with clothing around their neck.

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

On 12/20/2022, the Administrator reported an attempted suicide at the facility by [Child 1]. [...] FM Dewalt called 911 as the Administrator Losh and Staff Scholes started CPR. [Child 1] was transported to Saint Joseph's hospital in Stockton then Life-flighted to Oakland Children's Hospital. [...] [Child 1] was pronounced deceased on 12/22/22 at 10:30 pm. [...] The cause of death was listed as suicide by hanging.

From the state's report. Deficiency cited at inspection. "[...]" 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.

Under Health and Safety Code section 1548(f)(1)(C)(ii), a violation that the Department determines results in physical abuse as defined in section 1548(f)(2) to a child receiving care through a STRTP, there shall be a civil penalty of $2500.00. Under H&S 1548, "physical abuse" includes neglect as defined in 11165.2 of the Penal Code, when the person responsible for the child's welfare is a licensee, administrator, or employee of any facility licensed to care for children. A copy of this report, the Confidential Names Form, Appeal Rights, and the signed LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.

From the state's report. Deficiency cited at inspection.

Individual #1 was able to obtain large quantities of each medication from Employee #1’s personal belongings, and later ingest these medications while on the unit, which resulted in the individual being hospitalized and whom later died.

Therefore, Individual #1 had an opportunity to ingest Employee #1’s medications, which resulted in the individual being hospitalized, and whom later died.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-60. K. Providers shall not engage in willful action or gross negligence that jeopardizes the care or protection of residents.; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;.

LPA Diaz asked for medical documentation and further information regarding to [Child 1]'s death. At this time LPA Diaz was informed that the incident continues to be under investigation with the Sheriff Department. [...] At the time of this report, the cause of death had not yet been determined.

From the state's report. Deficiency cited at inspection. "[...]" 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: An investigation found the facility failed to properly supervise young people, leading to emergency hospital care for two clients. The state issued a civil penalty for physical abuse resulting in serious injury. Our summary of the state's report. The state's own wording follows.

The complaint, which was conducted by CCL Investigations Branch, alleged that the facility failed to properly supervise clients resulting in emergency attention and hospitalization for two clients. [...] The Department determined issuance of Civil Penalty per Health and Safety Code 1548 (f)(C)(i) For a violation that the department determines constitutes physical abuse, as defined in paragraph (2), or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a person receiving care at, but not limited to, short-term residential therapeutic program. [...] A copy of this report, Confidential Names Form, Appeal Rights, and form UC 421-D(CRP) for a Civil Penalty Assessment- Death/ Serious Bodily Injury/ Physical Abuse were provided to Facility Representative.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

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.

In plain words: A staff member sexually abused a client multiple times during one‑on‑one walks on facility grounds, and the state gave the facility a report and civil‑penalty forms. Our summary of the state's report. The state's own wording follows.

LPA Yamamoto met with the facility representative named above and discussed the following: On 3/4/21, the Department received a complaint that staff sexually abused client in care and engaged in conduct inimical to clients in care. Confidential statements obtained during the investigation revealed that the sexual abuse occurred multiple times on facility grounds when client and staff went for one on one walks. [...] Per Health and Safety Code section 1548(2), "physical abuse" includes sexual abuse as defined by Penal Code section 11165.1 which includes Section 288a oral copulation. [...] A copy of this signed report, Confidential Names Form (LIC 811), Appeal Rights and Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

LPA Yamamoto met with the facility representative named above and discussed the following: On 1/25/21, the Department received an incident report that on 1/23/21, a client in placement was found unresponsive at the facility after staff exited a bathroom. Staff called 911 and first responders arrived. Client was taken by paramedics to the hospital where client later died. On the same day, the Department received a complaint alleging neglect/lack of supervision resulting in a client's death. [...] A copy of this signed report, Confidential Names Form (LIC 811), Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse and Appeal Rights were provided to the facility representative.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

The Department received a complaint alleging that a client, who was left unsupervised, choked on food resulting in client's death. [...] Staff called 911 and was instructed to perform chest compressions by the 911 operator. [...] Client passed away at the hospital.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

In plain words: The state investigated a complaint that a staff member failed to properly supervise a fifteen-year-old resident before the child died. The state determined the violation resulted in the resident's death and issued an immediate seven thousand dollar fine to the program. Our summary of the state's report. The state's own wording follows.

On July 23, 2021, the Department concluded a complaint investigation alleging that staff #1 (See the Confidential Names List, LIC 811, dated September 3, 2021) neglected to provide the supervision necessary to meet the needs of fifteen-year-old client #1, prior to [Child 1]'s death. [...] Pursuant to the Enhanced Civil Penalty law, the Health and Safety (H&S) code section 1548 (e)(3)(A) states a violation the Department determines "...resulted in the death of a person receiving care through a Short Term Residential Therapeutic Program," the Department will be issuing an immediate civil penalty of $7,000.00." An exit interview was completed and appeal rights discussed. Copies of this report, the Confidential Names List, Appeal Rights and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the executive director.

From the state's report. Deficiency cited at inspection. "[...]" 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 16, 2021, CCL received an allegation that staff (Staff #1) neglected a minor (Child #1) resulting in a death. [...] Based on record review, observation of video footage, and confidential interviews the allegation that staff (Staff #1) neglected a minor (Child #1) resulting in a death is substantiated.

From the state's report. Substantiated. Cited: 87078(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.

The purpose of inspection is to deliver the case management investigation findings of the reported death of non minor dependent participant on 02/26/21. [...] Confidential Interviews and documentation reveal that program staff were aware of ongoing issues that were happening at the apartment complex which resulted in the death of a non-minor dependent participant in care.

From the state's report. Deficiency cited at inspection. "[...]" marks text left out between sentences.

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..

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.

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.

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.

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.

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.

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.

(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.