Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" 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 March 24, 2026, three clients (C1-C3) ran away from the facility, climbed into dumpsters, and ingested unknown items. Staff called 9-1-1 and took [Child 1] to an emergency room after s/he repeatedly vomited.

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

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

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

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

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

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

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

During the inspection, investigative interviews with several clients disclosed a staff member making inappropriate sexual and homophobic remarks.

During the inspection, investigative interviews revealed that a client had eloped from the facility. Upon return, the provider failed to conduct a search of the client who had concealed a box opener on their person and ultimately self harmed with it, cutting their arm and neck.

During the inspection, investigative interviews revealed that a client had swallowed a battery. The provider did not seek immediate medical attention or send the client to the Emergency Room.

From the state's report. Out of compliance, complaint, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights; R380-80-5(4) Provider shall protect clients from abuse, prevent abuse.

Allegations of Inhumane Treatment on or about July 2025, in that a student with a severe Traumatic Brain Injury (TBI) was allegedly placed in seclusion for weeks and instructed to use a bucket with a trash bag as a toilet.

A youth reportedly took hand sanitizer from a teacher's desk and ingested an unknown quantity, leading to an emergency room visit.

From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 23 Child and Family (Parent, Guardian) Rights; Chapter 3, Section 18 Facility Health and Safety Requirements.

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

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

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

In plain words: { summary: During an incident, a child bit a staff member, and the child was later taken to the hospital. A video showed the staff member putting the child in a chokehold. Police later arrested the staff member on charges of cruelty to children and assault. } Our summary of the state's report. The state's own wording follows.

During this process, Resident #2 bit Staff B. Lastly, the IIF stated that Staff B was arrested on cruelty to children allegations and Resident #2 was transported to the hospital for evaluation and treatment. [...] Staff A further stated that Resident #2 stated that Staff B choked Resident #2 and he/she could not breathe. [...] Review on June 10, 2026 of the ring camera video revealed that Staff B was seen on the ground with Resident #2 in what appeared to be a chokehold. [...] Review on June 12, 2026 of the police report, dated April 5, 2026 that at approximately 1900 hours Staff B was arrested on allegations of aggravated assault, cruelty to children in the first degree, and 3 counts of cruelty to children in the 3rd degree for allegedly placing Resident #2 in a chokehold while punching Resident #2 for an extensive period of time in the presence of three juveniles.

From the state's report. Deficiency cited, severity D, incident survey. "[...]" marks text left out between sentences.

In plain words: { summary: Medical and police records showed potential bodily fluid on a child in the program during an exam. The child reported that a staff member gave them a THC vape pen during a sexual assault. The state found that the facility failed to respond to the sexual assault and provide necessary care because four staff members did not report it until the child called for help. } Our summary of the state's report. The state's own wording follows.

A. Maltreatment: Regarding Sexual Abuse Information provided in [the alleged victim]’s medical record and in law enforcement information showed that during [the alleged victim]’s SANE exam, speckled fluorescence appeared under ultraviolet light that indicated potential bodily fluid. [...] Sexual abuse includes threatened sexual abuse.) Regarding Neglect The [the alleged victim] provided consistent information that [the staff person] provided [the alleged victim] with a THC vape pen during the time of the sexual assault. [...] Additionally, given that [the alleged victim] called and reported the sexual assault him/herself, after four staff persons with various levels of authority failed to report the incident, and that without [the alleged victim] reporting the incident him/herself the alleged sexual assault would have not been investigated there was a preponderance of the evidence that the facility failed to respond to a sexual assault and supply [the alleged victim] with necessary care and services.

From the state's report. Maltreatment Determined as to sexual abuse and neglect of an alleged victim by a staff person.. "[...]" 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.

According to the report, Resident #1 indicated that the staff members at the facility would not allow him/her to call Law Enforcement or Emergency Medical Services (EMS) for medical attention. It was further revealed that Resident #1 ran away from the facility for a short period of time. Lastly, it was reported that Resident #1 returned and waited on the facility front porch for law enforcement and EMS that brought him/her to hospital. [...] According to the report, Resident #2, Resident #3, and Resident #4 went to a truck stop where they were picked up by an adult male who brought them to a motel where six (6) men allegedly sexually assaulted them. It was further revealed that local law enforcement was called to the motel and two of the men were subsequently arrested.

From the state's report. Deficiency cited, severity D, licensure complaint survey. "[...]" marks text left out between sentences.

The [the alleged victim] was taken to the emergency department of the hospital where s/he was evaluated and diagnosed with an open displaced fracture and laceration of his/her right index finger and a laceration of the right little finger. [...] Staff persons were not permitted to push or shove youth and [the staff person] should not have closed the bedroom door without ensuring that the doorway was clear.

From the state's report. Maltreatment determined as to physical abuse of the alleged victim by the staff person.. "[...]" 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 2/18/2026, a staff member punched a client. The client was injured and got stitches in their mouth.

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

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

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

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

In plain words: { summary: State reviews showed past facility incidents. These included youth engaging in sexual acts on social media, self-harm, running away, physical fights, hospitalizations for suicide concerns and pregnancy, and crisis center calls. } Our summary of the state's report. The state's own wording follows.

Review on January 14, 2026 at 1:30 p.m. of a list of significant incidents reported by the facility in the previous 36 months to another state entity revealed the following reportable incidents: 1) On 3/30/23, a youth was caught performing sexual acts with men on social media. [...] 3) On 6/20/23, a youth was taken to the hospital for cutting his/her arms and legs. [...] 8) On 9/26/23, a youth ran away from work. [...] 10) On 10/11/23, a youth was taken to the hospital for treatment due to a physical altercation with another youth. [...] 13) On 12/4/23, a youth was taken to the hospital for suicidal thoughts and statements. [...] One youth was taken to the hospital to be checked out due to being pregnant. [...] 22) On 3/24/24, a local crisis center was called due to youth cutting his/herself and swallowing glass. [...] 28) On 6/25/24, a youth was 1013’d for suicide attempt. [...] 42) On 10/21/25, a youth was 1013’d for attempting suicide.

From the state's report. Deficiency cited, severity E, licensure complaint survey. "[...]" marks text left out between sentences.

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

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

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

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

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

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.

On May 2, 2025, Community Care Licensing (CCL) received the allegations that staff ([Staff 1]) handled a minor ([Child 1]) in a rough manner and that staff ([Staff 1]) bit a minor ([Child 1]) while in care. [...] It was further reported that [Child 1] was admitted to a psychiatric hospital following the incident due to being considered a danger to others. ...CONTINUED A review of video and photo evidence revealed that [Staff 1] bit [Child 1] during a physical altercation at night outside, while [Child 1] was holding [Staff 1] down. [...] Based on confidential interviews and records reviewed, the allegations that staff handled a minor in a rough manner and staff bit minor in care are substantiated because the preponderance of evidence has been met.

From the state's report. Substantiated. Cited: 87072(c)(1), 87072(c)(16). "[...]" 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.

Specifically, it was reported that an incident occurred on facility ground on or about 2/2/2025, resulting in [Child 1] being taken to the hospital. [...] ***Continue LIC-812C*** Record review further revealed the facility had requested and been approved to have a one-to-one staff assigned to [Child 2], due to previous assaultive behaviors.

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.

The nurse determined that Urgent Care or ER services were not needed and recommended that a PCP appointment be scheduled for further evaluation. [...] Shorty after, around 1450 the Member got up from [Resident 1's] seat and rushed towards [Resident 1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head.

From the state's report. Deficiency cited, complaint. Cited: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

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

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

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

In plain words: A staff member and a child fought after the child struck the staff member. The staff member repeatedly slapped, kicked, and punched the child, leaving scratches and a welt on the child's face. Our summary of the state's report. The state's own wording follows.

The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [Resident 1]'s face. [...] Staff then challenged the client, at which point the client lunged towards staff and struck [Staff 5] in the head. Staff raised [their], slapped the client and began punching [Resident 1] with a closed fist. [...] Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [Staff 5's] hair. Staff then became more aggressive by grabbing and hitting the client again.

[Staff 5] slaps [Resident 1] eight times and kicks them once (15:16:39-15:16:45).

[Staff 5] pushes [Resident 1], grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48).

From the state's report. Deficiency cited, complaint and initial monitoring. Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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 August 7, 2025, the client's severe self-harm required transport to the emergency room for treatment and necessitated multiple sutures. Three days later, the client was not adequately supervised and self-harmed again by removing multiple sutures from the prior injury. This incident resulted in a second transport to the emergency room for additional treatment.

During the investigation inspection, the evidence substantiated that on September 17, 2025, a client with a history of significant self-injurious behavior engaged in a serious self-harm incident that resulted in a transport to the emergency room which necessitated over 30 sutures. A second client engaged in self-harm with the same contraband which also resulted in transport to the emergency room and sutures.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(10) Services and supervision to meet each clients needs.

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

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

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

The document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program slammed a bedroom door, and a staff member allegedly followed, screamed and cursed, and shoved the child. Another child reported that the staff member pushed the door open, hitting and hurting the first child's arm. Our summary of the state's report. The state's own wording follows.

Client #3 was sent to the emergency department for an X-ray of the left wrist. [...] Client #3 went into their bedroom and slammed the door, then [Mental health technician 1] came into the room, slammed the door, screamed, "Don't slam this [expletive] door!" Client #3 stated, "I won't slam this [expletive] door in a sassy way." The client reported being shoved into the " cubby " by [Mental health technician 1], and then being put into a PRT and taken out into the hallway. [...] One second later, [Mental health technician 1] was seen aggressively pushing past Client #4 who was standing in the doorway. [...] [Mental health technician 1] reported that she heard small plastic blocks hit the floor. [...] Client #4 reported that Client #3 had gone into the bedroom and slammed the door and was behind the door when [Mental health technician 1] pushed the door open and it hit Client #3 and hurt their arm. [...] Client #3 stated that [Mental health technician 1] came into the bedroom, slammed the door and started screaming and cursing.

From the state's report. Deficiency cited, recertification survey. Cited: N 128 PROTECTION OF RESIDENTS N 128 The Resident affected was assessed by Nursing and. "[...]" 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 an inspection on 4/28/2025 it was reported that a staff left line of sight supervision of the clients and a client was able to obtain benadryl, which they later ingested with the result of being taken to the hospital.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(10) Services and supervision to meet each clients needs.

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.

Findings include: Review on December 9, 2024 at 12:20 p.m. of the Intake Information Form (IIF) for intake GA00181418 revealed that on the night of November 11, 2024, Resident #1 was admitted to the hospital due to ingesting 10 pills. [...] Additionally, Staff C indicated that he/she called 911 and the crisis line, and once the ambulance arrived, Resident #1 stated that he/she had broken into the medication room and took 10 pills.

From the state's report. Deficiency cited, severity G, incident survey. "[...]" marks text left out between sentences.

On 5/13/2024, Community Care Licensing Division (CCLD) received an allegation that on 4/24/2024, Client ([Child 1]) was transported to the hospital following an attempted suicide by hanging with a belt (refer to LIC811, dated 10/15/2024). [...] Staff on duty brought [Child 1] down and performed cardiopulmonary resuscitation (CPR) until paramedics arrived. [Child 1] was resuscitated, transported to the hospital, intubated, and diagnosed with Hypoxia. [...] Based on confidential interviews, record review, and analysis of circumstances, the Department has determined that the preponderance of evidence standard has been met; therefore, the allegation that staff did not provide necessary care and supervision to [Child 1] resulting in [Child 1]'s attempted suicide by hanging with a belt while in care is substantiated.

From the state's report. Substantiated. Cited: 84078(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.

Lastly, Staff D indicated that later that evening Resident #1 reported his/her injuries to staff and was taken to the hospital. [...] Resident #1 further stated that he/she swung at Staff B and tried gorging his/her left eye out and Staff B slammed Resident #1 to the ground pressing his/her face to the ground.

From the state's report. Deficiency cited, severity D, licensure complaint survey. "[...]" marks text left out between sentences.

Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. [...] 1. A review of [Resident 1]' s medical record revealed an incident report of a medical overdose by [Resident 1] on September 1, 2024. The report stated "At med pass, [Resident 1] was given [Resident 1] seroquel and [Resident 1] took the bottle, emptied it into [Resident 1] mouth, and swallowed 13 or 14 tablets." The report indicated [Staff 4] contacted 911 and poison control, and [Resident 1] was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of [Resident 1]'s self-injury was not available for review.

The assessment stated [Resident 1] is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a ...; A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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: Medical records showed one child went to the hospital after an injury and was put on meal lockouts and frequent checks. Another child was taken to the emergency room due to self-harm, and the state requested an internal investigation. Our summary of the state's report. The state's own wording follows.

Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. [...] Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1.

From the state's report. Deficiency cited, complaint. Cited: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health .... "[...]" marks text left out between sentences.

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

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

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

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

In plain words: A child in the program reported injuries after a physical restraint by multiple staff members. The child was sent to the emergency room for an evaluation and returned the next day. Our summary of the state's report. The state's own wording follows.

(Patient # 11) was sent to Valleywise ED for further evaluation as a precaution...." A review of a progress notes for Patient # 11 dated May 26, 2023 revealed "...Resident reported injuries sustained from his continued struggling against a code gray...restraint that required multiple staff to control him...guarding/pain at his left shoulder and elbow....He will be sent to the ER this evening for evaluation...." Employee # 1 confirmed in an interview on March 28, 2024, that Patient # 11 was sent to the emergency room for an evaluation on May 26, 2023 and returned on May 27, 2023.

From the state's report. Deficiency cited, complaint. Cited: R9-10-1302. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover ....

The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [Resident 1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [Resident 1] to the hospital where [Resident 1] was treated for first degree burns to [Resident 1's] chest." 2. [...] 3. In an interview, [Staff 1] and [Staff 2] reported the first peer who threw water on [Resident 1] used hot water and the second peer used cold water, after [Staff 1] and [Staff 2] investigated the incident. [Staff 1] and [Staff 2] reported removing the peer who threw hot water from the facility and relocating the peer who threw cold water.

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. "[...]" 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 complainant’s statement that Resident A reported to emergency room staff that a peer sexually assaulted them.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.20(a) Program staff shall provide care and supervision at all times to ensure that residents are safe and that their needs are met according to their ....

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.

In turn, [Resident 1] became intoxicated and had to be transported to the local hospital for assessment. [...] 4. In an interview, [Staff 1] acknowledged, as a result, [Resident 1] ingested alcohol, which caused [Resident 1] to be under the influence, where [Resident 1] was transported to the hospital for a medical assessment.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

[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.

Based on review of the internal incident report, the provider failed to implement prompt emergency care to Resident #1 after Resident #1 experienced a suicide attempt. There was a 9-minute period between the time Resident #1 was found after the suicide attempt and the provider decision to call EMS. Per video review of the incident, Resident #1 was discovered by Staff #1 and #2 at 5:01pm after the suicide attempt. Per the incident report, after a few minutes of asking Resident #1 questions, Staff #2 and Staff #6 made the determination that EMS personnel were needed and made a 911 telephone call. The incident report explained the call to EMS was not made until, "about 5:10pm," which was after the internal nursing staff was contacted.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-810. A. (3) The provider shall have and implement written procedures for promptly: 3. Providing emergency services for each resident;; 12VAC35-46-810. A. (4) The provider shall have and implement written procedures for promptly: 4. Providing emergency services for any resident experiencing or ....

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.

The report stated [Resident 3] and [Resident 5] appeared to be "under the influence," as staff questioned [Resident 3] and [Resident 5], it was discovered [Resident 3] and [Resident 5] had ingested eight unprescribed Oxcarbazepine 600 mg capsules each, given to [Resident 3] and [Resident 5] by [Resident 2], who had taken the pills during assistance with the self-administration of medication, without staff noticing. Both [Resident 3] and [Resident 5] were transported to the nearest emergency room location in Maricopa.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

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

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

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;.

Staff were not aware and accountable of a child's activities when the child was able to obtain a razor and cut themselves seriously enough to where the child required medical attention and had stitches for the injury.

From the state's report. Risk level: High. Cited: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity.

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

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

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

([Child 1]) was upset with ([Staff 1]) and threatened ([Staff 1]) and started hitting the staff member, which resulted in ([Staff 1]) stabbing ([Child 1]) in the left abdomen. The facility contacted the authorities, and ([Child 1]) was transported to the hospital by ambulance.

From the state's report. Substantiated. 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.