Severe reports

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.

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.

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: 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.

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 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.

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.

[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.

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.

In plain words: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.

8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" 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 conducted an inappropriate restraint on client #3 face down on the couch. Client #4 was injured during the physical altercation and required six stitches for a laceration above her eye.

From the state's report. Deficiency cited, follow-up survey, Type A1 violation. Cited: {V 293}.

Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.

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

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

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