The most serious findings in the state inspection reports we hold: deaths, sexual and physical abuse, restraints that injured a child, suicide attempts, medical neglect and hospitalisations. Every quote below is the licensing agency's own wording, and each one was read against its report by a person before it was listed here.
During an incident that occurred on 11/25/2020, Staff Member A punched Child #1 in the leg multiple times during a restraint. [...] During an incident that occurred on 11/25/2020, Staff Member B punched Child #1 in the face multiple times.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32 Specific Rights. "[...]" marks text left out between sentences.
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}.
Staff intervened and resident then began slapping, punching, and kicking at staff when redirecting resident out from under the peer's bed.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 126 PROTECTION OF RESIDENTS N 126.
"staff were in a crisis." -kid called staff the "n word" and other kid ran in kid's room and beat him up.
From the state's report. Deficiency cited, complaint and follow-up survey, Type A violation. Cited: V 314) 27G .1901 Psych Res. Tx. Facility - Scope.
Discharge Summary completed by Licensee #1/Director/Qualified Professional #1 dated 8/6/20 revealed stealing peers' clothing, struggling with telling the truth, physical assault by pushing a peer off the couch, and a sexual assault allegation;
No incident reports regarding an allegation of abuse involving Staff #8 choking Former Client Interview on 8/10/20 with Licensee #1/Director/Qualified Professional #1 revealed: The local Department of Social Services (DSS) was in process of investigating an allegation of abuse involving Staff #8 choking Former Client
Former clients were allowed to play in each other's rooms until" ...[Former Client #4] started raping [Former Client #2] ...;"
From the state's report. Deficiency cited, complaint survey; Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint s. Cited: V 366; V 132; V 293.
Per interviews with children, staff A and B who were in the home at the time were aware that child was struck in the head.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.k Specific Rights.
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..
The findings of this investigation indicate that Staff 1 engaged in a physical altercation/corporal punishment with Youth A in violation of the facility’s discipline policies and this rule.
From the state's report. Violation established, special investigation. Cited: R 400.158 Discipline.
The findings of this investigation substantiate that Staff 1 implemented an improper restraint of Youth A by restraining Youth A in a prone position.
From the state's report. Violation established, special investigation. Cited: R 400.4157 Behavior management.
On 10/16/2079, child 1 was subjected to mistreatment/corporal punishment by staff member A during an incident at the facility.
From the state's report. Citation, complaint inspection.
In plain words: Video footage showed a staff member pushing one child into a room and blocking the door with a chair. The staff member also pulled another child by the shirt and blocked a third child, causing that child to fall. Finally, the staff member dragged the first child by the ankle across the floor. Our summary of the state's report. The state's own wording follows.
Per video surveillance footage review, Staff Member A is scon pushing Child # 1 into his/her coom and placing a large wooden chair In front of Child # {'s door and sits in the chair, which is blocking Child # 1 from exiting the room. [...] Regulation- 3800.32(b)- A child may not be abused, mistreated, threatened, harassed or subject to corporal punishment morning of 10/20/19, Staff Member A is seen pushing Child #1 into his bedroom, pulls Child #2 backwards by his shirt while the Child #2 is attempting to walk down the hallway, and is physically blocking Child #3 from walking down the hallway which makes Child #3 fall to the floor. [...] Child #1 falls to the floor and Staff Member A grabs Child #1’s foot/ankle and picks his leg up, Staff Member A takes a couple of steps while holding Child#1’s foot/ankle and drags Child#1 on the floor for approximately 2-3 feet.
From the state's report. Citation. "[...]" marks text left out between sentences.
Resident was throwing cups on the unit which upset one of his peer to where resident tried to fight the peer but staff intervene and got hit by resident. [...] Resident began to hit and kick staff spitting and scratching at staff when they blocked his blows, kicking in restraint repeatedly. [...] Resident attacked peers and staff, punching, hitting and kicking. [...] Resident Behavior ... [Resident] fighting with staff in restraint, shoving, kicking, biting and scratching in restraint ..." This progress note was signed by the physician on 9/22/19 at 10:00 a.m. 7.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 131 PROTECTION OF RESIDENTS N 131. "[...]" marks text left out between sentences.
Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van. [...] Was brought into the library by Staff #4 when he attempted to elope and Staff #4 who grabbed his shirt and pushed him against the wall; [...] Client #1 made an allegation against Staff #5 regarding Staff #5 using a choke hold while on the van, Review on 10/2/19 of the North Carolina Incident Response Improvement System revealed:
From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V132. "[...]" marks text left out between sentences.
In plain words: A client said a former staff member forced him to perform oral sex and sexually abused him on two dates after earlier inappropriate touching. The client told a staff member, who reported the abuse to a qualified professional and the program’s licensee. Our summary of the state's report. The state's own wording follows.
"[Client #2] further stated that he was forced to perform oral sex on [Former staff 11] on May 19, 2019 around 9 pm while at the facility. [Client #2] stated that [Former staff 11] stood up and told [client #2] to come over to where he was standing and grabbed his head and pulled his head down to his penis area." [...] He was sexually abused by [Former staff 11] on 5/17/19 and 5/19/19. Three to four weeks prior to 5/17/19 and 5/19/19 sexual assaults, [Former staff 11] had touched his butt "like four times before." [...] Denied that he ever told [Former staff 11] about his past or that he was sexually abused. [...] Client #2 made her aware that [Former staff 11] sexually abused him and she contacted the QP, the Licensee #1 and an unknown staff. [...] On 5/20/19 at approximately 12:27 a.m. he received a call from the QP that [Former staff 11] has allegedly sexually abused client #2. [...] And he said the guy eventually molested him.
From the state's report. Deficiency cited, 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.
The facility failed to meet the regulatory requirements for Protection of Residents at N128, as evidenced by the facility's failure to ensure Resident #1 was freé from injury during a restraint. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Client #1 was asked, "Were you injured during the restraint?" The client stated, "Yeah, there was a knot behind my ear... [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d.
From the state's report. Deficiency cited, complaint survey. "[...]" marks text left out between sentences.
The MP had built a program for boys "that a [North Carolina (NC) law enforcement association] could model statewide;" [...] 2/12/17 Juvenile Petition: physically abused and injured or sexually abused by parents Interview on 6/25/18 with Client #1 revealed: [...] Staff #14 "had put him (Client #6) on the floor on his stomach because he started punching stuff and being violent;" [...] Staff #14 and Staff #13 told him he had no rights and then had slammed him on the floor trying to restrain him; [...] Staff #14 had left Client #2 at the "temple" or "mud dog"( public baseball field with concrete/rock stairs) to work out running up the stairs and around the ball field because Client #2 had said he was going to run away; [...] Staff #14 had worked for the local Sheriff's Department for 2 % years; [...] Staff #14 walked back to the client's room and Client #5 was kicking the bed and thumping the wall;
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 514. "[...]" marks text left out between sentences.
In plain words: The facility failed to ensure a doctor was told about an alleged physical abuse incident involving a patient. The facility also failed to ensure a doctor examined the patient within twelve hours as required. Our summary of the state's report. The state's own wording follows.
Based on review of facility documents, clinical record review and staff interview it was determined the facility failed to ensure the Program Manager or the Nursing Supervisor notified the Attending Physician of the allegation of physical abuse and the facility failed to ensure the Attending Physician or the Medical Director assessed Patient #1 within twelve (12) hours of the alleged physical abuse per facility policy. [...] The attending physician or the Medical Director may order that the patient be transferred to Charleston Area Medical Center for evaluation of physical or sexual abuse allegations." 2.
From the state's report. Deficiency cited, complaint survey. Cited: N 196 483.372(a) MEDICAL TREATMENT FOR INJURIES. "[...]" marks text left out between sentences.
Child # 1 starts to scratch his/her arm, and 47 seconds later Staff Member A initiates a restraint on Child #1. During the restraint Staff Member Ais seen slamming Child # 1’s face off of a table twice, dragging Child # 1 off of a Chair by his/her left arm, and tifting Child #1 in the air by the left arm, while Child # 1 is sitting on the floor.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.32.b.
Staff Member A was observed on video shoving Child #1 inside the bedroom and closing the door several times behind them.
On Staff Member A was observed on Video Physically shoving another resident which caused the resident to fall and hurt their arm.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.53.b.
Based 6n child and staff interviews as well as video footage review and pictorial documentation of injuries, the investigation determined that Child #2 was involved in an improper restraint ona ith Staff Member B and Staff Member C.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.202.b.
In plain words: A staff member punched a child in the face multiple times and cursed at them while multiple staff members held and carried the child. The facility also failed to report the assault to the department and contracting agency within twenty-four hours as required. Our summary of the state's report. The state's own wording follows.
Child #1 was restrained and physically escorted by Staff members A, 8, C, D, E, F, G, H, During (he escort, Staff person A was observed punching Child #4 In the face multiple (Imes and repeatedly told Child #4 to “shut the {_k up.” Stalf person A Was also observed on a video of the event continulng fo punch Ihe chitd in the face while the child was carted dovm the hallway by Stalf members B, 0,D,€,F,G,H In a continual restraint, Child #4 sustalned mutiple tnfurles as a result of the ascault by StaffA. [...] Tho Spectal Victlms Unit was contacted and résponded by assigning a detective (Datectiva Danlel OMalley #895} tothe case.
On BE chiia #1 was assaulted by Staff A. ‘The facllly failed lo complete a written reportable incident report on a form prescribed by the Department; send it_fo the approprlate Departmental office and contracting agency within 24 hours. —
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.18.c. "[...]" marks text left out between sentences.
Child: #1 was physically assaulted by Child #2 several times, which resulted in substantial-bruising on Child #1.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
During restraint on 08/02/2016 at 7:10 AM, Staff Member B used his/her back leg to push Child # 1's head and chest forward to Child #1's knees, while Child # 1 was sitting with his/her legs out on the floor, causing pressure and weight on Chitd # 1's respiratory system.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.211.b.
On 07/17/2016 during a restraint, Staff Member A used his/her leg to push into the back of Child #1, while pulling Child #1's arms behind him/her, causing pain in Child # 1's shoulder.
on 07/17/2016 during a restraint, Staff Member A used hissher leg to push into the back of Child #1 while pulling the arms of Child #1 behind hinvher in an effort to make Child #1 apologize to resident staif.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.202.a.
Between February and March of 2016, Child #1 was twice subjected to sexual abuse by Child #2 and Child #3. The instances of sexual abuse occurred in the bedroom shared by Child #1 and Child #3. Child #2 forced Child #1 fo perform oral sex on Child #2 and Child #3 by threatening Child #1 with bodily harm if he/she did not comply. [...] Interviews with children confirmed that the assault was in retaliation for the sexual assault referenced above. [...] Staff Member A told the children "you know what needs to be done", and "you know what needs to happen.” Staff Member A was told by one of the children "go to your room” while the assault happened.
On Saturday April 2, 2016, Child #1 disclosed to Staff member A that a sexual assault was perpetrated on him/her by Child #2 and Child #3.
Staff Member A was aware of the physical assault on the date it occurred.
From the state's report. Citation, renewal inspection, licence action taken. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.15.a; 55 Pa. Code § 3800.16.c. "[...]" marks text left out between sentences.
On Saturday April 2, 2016, Staff Member A did not provide adequate supervision to Child #6, Child #8 and Child #9 who absconded from the program and entered the upstairs program, at approximately 11:00 PM, where they participated along with children from the upstairs program in a physical assault on Child #2 and Child #3.
From the state's report. Citation, renewal inspection, licence action taken. Cited: 55 Pa. Code § 3800.55.f.
In plain words: One staff member kicked a child in the behind. Another staff member pressed their forearm into the back of a second child's neck. A third staff member threw, pushed, and knocked a third child into a quiet room. Our summary of the state's report. The state's own wording follows.
Slaff Member A let go of Child #1 and when Child #4 got up and altempted to leave the room Staff Member A kicked Child #1 In the behind. [...] Staff Member B came up behind Child #2 and placed thelr forearm into the back of the neck of Child #2 and pressed their weight onto the back of Child #2, On 1/11/2016, Slaff Member C and Child #3 were In the qutet room, Child #3 altempted to leave the quiet room and Staff Member C picked up and threw Child #3 back Into the quite room. Staff Member C also pushed Child #3 Into the wall and onto the ground while attempting to keep her In the quiet room.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b. "[...]" marks text left out between sentences.
In plain words: A staff member dragged a child along a gravel pathway by one arm. The child was evaluated the next day, and a nurse documented a purple bruise on the left shin and a red scratch on the back. Our summary of the state's report. The state's own wording follows.
On 4/12/2016 at approximately 7:30 P.M., While returning to the van from a Ip to a park, Staff Member A dragged Resident H along a gravel pathway by one of Resident /#1's arms for approximately 10 feel, Resident #1 was on hisMer knees and ended up on his/her back while belng dragged, As a result, on 4/13/2016 af approximately 11:04 A.M., Restdent #1 was evaluated by a lloensed practloal nurse and the following Injurlos wore documented, “pusple brulso on left shin and rod soratch on loft site of back.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.h.
To release Child #1's grip, Staff Member A bit Child #1 resulting in 2 bite marks to his/her fight forearm.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
Shorily prior to discharge on 2/18/14 Child # 2 was picked up and slammed by Staff Member A onto the floor of hishher bedroom resulting in the child's lip bleeding.
Shortly prior to discharge on 2/18/14 Child # 2 was picked up and slammed by Staff Member A onto ihe floor of hishher bedroom resulting In the child's tip bleeding.
From the state's report. Citation, complaint, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
On 3/16/2014 at 6:30pm Staff member A witnessed Staff member 8 kick Child 4 in the leg causing the child to fall to the ground, Staff member A stated that Staff member B, who was Child 1's 1:1 at ihe time, kicked the child.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.205.b.
On 02/06/14 at approximately 11:15 a.m., Staff Person A grabbed Child #1 by the collar of hand on the child's back, Staff Person A pushed Child #7 down the stairs resulting in the C, who was on the second floor landing of the staircase, and Staff Person B, who was on witnessed the incident.
Staff Person A grabbed Chitd #1 by the collar of his/her sweatshirt, and with one hand on the collar of the child's sweatshirt and one hand on the child's back, Staff Person A pushed Child #1 down the stairs resulting in the child falling on his/her buttocks. On 02/08/14 at approximately 11:50 a.m., Staff Person A used one hand to push Chitd #1 out of the chair of the kitchen table onto the floor causing the child to hit hishhar haad off of a metal heater.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.15.a; 55 Pa. Code § 3800.32.b.
Child # 1 was the victim of an indicated case of physical abuse in an assault by Staff Member A that caused Child # 1 to be hospitalized,
From the state's report. Citation, j ‘type of inspection: partial bha docket number: notice: un inspection. Cited: 55 Pa. Code § 3800.32.b.
Child 4 eloped from the presence of his/her 7:1 staff member as the child exited the facility's vehicte following the transport to the child's school, Child 4 ran into the wooded area next to the school, The child's 1:1 staff member and 3 other staff members pursued the child. [...] Staff Member A was then removed from the restraint and separated from the child, The restraint technique utilized by Staff Member A was an Inappropriate restraint that was not within the scope of the restraint {raining that Staff Member A received on 5/30/2043.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.208.b. "[...]" marks text left out between sentences.
On 9/18/12, Child 1 was held face down on the floor during a prohibited manual restraint by Staff Member A, Child 1 received a laceration to the chin during the restraint process.
From the state's report. Citation. Cited: 55 Pa. Code § 3800.21.
Findings include: (a) Consumer #7 alleged on 6/15/01 that Staff A had sexually abused the consumer by the staff grabbing his crotch on three (3) separate occasions. [...] (b) On 8/23/01, the Center reported to the State IIU that Consumer #5, #6 and #3 alleged that they had been improperly restrained by Staff B and had sustained injuries as a result, over a two (2) week period of time. [...] (c) On 11/28/00, Consumer #8 alleged that Staff C dragged him across a room, pulled his arm and pushed the consumer into a chair two (2) weeks earlier.
From the state's report. Deficiency cited, survey. Cited: C 359 64-11-8.2.b. Violation of Consumer Rights. "[...]" marks text left out between sentences.
(b) While Consumer #6 alleged abuse (staff kicked him in the mouth) during the restraint which resulted in his assault charge, the abuse allegation was investigated internally. [...] (c) Consumer #1 was inappropriately restrained by Staff #30 on 3/17/01. [...] The consumer suffered a sprained wrist, requiring a trip to the emergency room, during the restraint. [...] Findings include: (a) Staff #5, according to internal investigation, was negligent in her duty to supervise Consumer #7 when he eloped on 1/29/01.
From the state's report. Deficiency cited, survey. Cited: C 102 64-11-5.2.a. Governing Body. "[...]" marks text left out between sentences.
For example, Consumer #1 hit his head on the wall and cursed staff on 5/6/00, 5/8/00, 5/15/00 and hit himself in the face on 5/21/00. On 5/15/00, the consumer injured himself so badly that he had to be taken to the emergency room of a hospital for treatment of his head injuries.
From the state's report. Deficiency cited, survey. Cited: C 243 64-11-7.3.d. Treatment Plan.
A program reads every inspection report we collect and picks out findings that describe serious harm, using the state's own severity rating or complaint outcome where there is one. A person then reads the report and approves or rejects each one. Only findings the state substantiated are listed: a citation, or a complaint the investigator upheld. A child running away is listed only when it ended in a death or a serious injury. This page is not complete: it covers the states and reports reviewed so far, and a facility's absence here says nothing about its record. Every report we hold, flagged or not, is on the state trackers.