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.

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

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

In plain words: A 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: 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.