Severe reports

Child A admitted to resisting, so Staff person A kept shoving Child A's head back onto the floor, using forearm on child's face and hand on child's head. [...] A medical consult concluded that the staff used excessive force and the act was diagnostic of child abuse as it created a reasonable likelihood of bodily injury and would have caused substantial pain and interfered with Child A's breathing. [...] Child B reported that staff member B was punching Child B in the face during this restraint; child reported that nose was bleeding during the incident.

From the state's report. Citation, complaint inspection, licence action taken. Cited: 55 Pa. Code § 3800.32.b Specific Rights. "[...]" marks text left out between sentences.

The agency is found in non-compliance as Youth C, Staff 1, Staff 2, Staff 4, Staff 5, and Supervisor all reported Staff 5 pushed Youth C against the wall which is not an approved restraint technique and is against Wolverine Center Policy.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Upon review of CHRIS entry A-20250006: Entity # 1's disposition received revealed the following: Individual #1's account of the incident was consistent regarding the inappropriate restraint which resulted in injury to Individual #1.

From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation..

On October 13, 2025, an allegation was made that staff member [Staff 2] struck client [Child 1] on the chest following a brief confrontation. [...] The allegation that [Staff 2] hit a minor in care is substantiated.

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

Staff L stated that "training was minimal" for new staff, and that many times staff "just got thrown in" with no training.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.19(n)(1) The licensee shall educate personnel about the needs and services required by the residents under their care and document such education to ....

Specifically, it was reported that [Staff 2] shoved a paper in [Child 1]'s face and smacked the tablet from [Child 1] and swung at [Child 1].

From the state's report. Substantiated. Cited: 87072(c)(1). 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 agency is found in non-compliance as per youth and staff interviews, documentation and video reviewed Staff 1 punched Youth A during the incident on 12/10/2025.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

In a review of the investigation, it was found that a caregiver pushed down on a child's face.

From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

Review on 11/26/25 and 1/16/26 of law enforcement call log from 9/1/25 through 1/13/26 revealed: [...] 9/20/25, 18:21 (6:21pm), MP-RUNWY (missing person-runaway) REPORT; [...] 12/11/25 13:27 (1:27pm), DV-ASLT (domestic violence-physical assault), SUSP-SCN; [...] 9/18/25, client #3 eloped, submitted on 9/22/25. 9/22/25 client #3 eloped, submitted on 10/2/25. [...] Purpose of Investigation: The purpose of this investigation is to review and assess allegations made by consumer, while in hospital for behaviors. [Client #2] alleged inappropriate staff conduct, including inappropriate touching, staff being under the influence of drugs, and staff fighting while on duty.

From the state's report. Deficiency cited, annual complaint and follow-up survey. Cited: V 367. "[...]" marks text left out between sentences.

Video surveillance showed that an improper restraint was utilized by staff member A, causing the child's in a forceful manner.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights.

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.

The facility is found in non-compliance as per interviews conducted, video reviewed, and documentation reviewed, Staff 1 got into a physical altercation with Youth A, which included Staff 1 punching and pushing Youth A multiple times.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

A staff was recorded on video pushing a child forward.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A) - Children's rights-The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment..

Staff 1 acknowledged pushing Youth A in an attempt to de-escalate the situation and protect herself; however, physical contact in the form of pushing a resident is prohibited under the agency’s Behavior Management Protocol and applicable CCI regulations.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

The agency is found to be in non-compliance as per interviews, documentation and vide review, it was found that Staff 1 punched Youth A in his face and pulled on his hair.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

A staff threatened to physically assault a child in care.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

I child in care was subjected to corporal punishment by a caregiver.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

It was reported that [Child 1] was pushed by [Staff 3] at the facility.

From the state's report. Substantiated. Cited: 84072(d)(1). 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 agency is found in noncompliance when Staff 1 punched Youth A on 11/04/2025 as stated by Youth A and shown in the video.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Lastly, it was noted that Staff B also grabbed Resident #1 by the hair dragging him/her to the closet, ripping out Resident #1’s hair and scratching Resident #1’s body.

From the state's report. Deficiency cited, severity G, incident survey.

In plain words: { summary: A child in the program alleged that one staff member slapped her in the face before two staff members put her in a restraint. The state found that the child was scratched during the restraint, and there was no record of an internal investigation. } Our summary of the state's report. The state's own wording follows.

There was no documentation of an internal investigation for the incident that took place on 11/9/25 when Client #7 alleged Staff #5 slapped her in the face before Staff #5 and Staff #6 put her in a restraint for aggressive behavior. [...] "[Client #7] pushed her (Staff #5) back and [Staff #5] slapped her (Client #7)." [...] "After she (Staff #5) slapped [Client #7], they (Staff #5 and Staff #6) tried to restrain her (Client [...] Cc "[Client #7] pushed [Staff #5] and [Staff #5] slapped her in the face." [...] She was restrained for being aggressive and she received the scratch on her face while being combative during the restraint."

On 11/9/25 Client #7 had to be restrained due to aggressive behavior, and alleged Staff #5 slapped her in the face causing a scratch on her (Client #7) cheek. [...] It was determined Client #7 was scratched on her face due to a restraint. [...] On 11/9/25 Client #7 alleged Staff #5 slapped her and scratched her cheek. [...] Based on Client #7's history of assaultive behavior, she determined that "[Client #7] scratched herself as she struggled with staff (Staff #5 and #6) during the restraint." Cc

From the state's report. Deficiency cited, complaint survey, Type A1 violation; Deficiency cited, complaint survey. Cited: V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect; V 132} G.S. 131E-256(G) HCPR-Notification,. "[...]" marks text left out between sentences.

"[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.

Video observation also reveals Staff 1 pushing Youth A into the wall and grabbing his upper shoulder area.

From the state's report. Violation established, special investigation. Cited: 400.10169.

The agency is found in non-compliance as per youth and staff interviews and documentation reviewed Staff 1 kicked and pushed Youth A during the incident that occurred on 10/20/2025.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Behavior Management: Staff member used improper restraint technique including wrapping his arms around the resident's neck.

From the state's report. Substantiated complaint. Cited: 340:110-3-154.2(d) Physical restraint. Restraint is used only when less restrictive interventions, per program policy, were attempted or ....

It was observed a staff member used excessive force to initiate a restraint by grabbing a child in care's arm from behind and swinging them into a door.

From the state's report. Risk level: High. Cited: 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.

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.

Staff physically assaulted client in care, Program does not allow clients to attend school of origin, Staff do not ensure that medication is readily available to clients, Facility is not addressing safety concerns of clients, Facility does not provide appropriate personal hygiene items. [...] Facility is being cited for violation of Interim Licensing Standards, Section, 87072(c)(1), 87072(d)(27), 87072(c)(16), and California Code of Regulations, Title 22, Division Six, Section 80075(b) Health related services, as described on the following LIC 9099-D. Civil pentalties are being assessed for Staff physically assaulting client in care and also for Staff not ensuring that medication is readily available to clients.

From the state's report. Substantiated. Cited: 87072(c)(1), 87072(d)(27), 87072(c)(16), 80075(b). "[...]" marks text left out between sentences.

The complainant reported that on November 19, 2025, Child A disclosed that they had bruises all over from staff restraining them and that staff threw them into a wall.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901..

The facility is found in noncompliance as per interviews and review of documentation Staff 1 was observed to have pushed Youth A and grab the back of Youth A’s shirt.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

Specifically, it was reported that on 05/06/ [Child 1] was in kitchen with [Staff 1] and they engaged in a verbal altercation led into [Child 1] hitting [Staff 1] on the head and [Staff 1] responded by pushing [Child 1]. [...] Interviews further revealed that [Staff 1] responded to being hit by jumping up from their chair and pushing [Child 1] into the fridge hard enough to make the fridge shake.

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

During the unnecessary physical restraint, a staff member pulled the client downward, causing the client’s head to strike the staff member’s knee and subsequently hit the floor; the client incurred a concussion.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(4) Provider shall protect clients from abuse, prevent abuse.

A caregiver shoved a toddler causing them to fall to the floor instead of using a less forceful technique such as blocking the toddler.

From the state's report. Risk level: High. Cited: 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.

Based on the video observed, staff was seen pushing child towards the wall and grabbing him by the neck.

From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.

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.

Staff B and Staff C each stated that during the restraint, there was a miscommunication leading to each staff member attempting a different restraint type, resulting in the resident hitting their head on a windowsill.

From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(e) Program staff shall use seclusion and restraint in accordance with RSA 126-U and He-C 901..

A caregiver became irate and shoved and physically aggressed a child.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

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.

Additional Non-Compliance Found During Investigation: Behavior Management: Staff member choked a resident.

From the state's report. Found during a substantiated complaint investigation. Cited: 340:110-3-154.2(b)(1) behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing ....

[Staff 1] later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. [...] The MAR stated “… Count off by 2 … 5/22/25 7:58 Chlorpromazine 25 given two to equal 50mg gave, nd [sic] two 25 mg at bedtime … 5/23/25 8:00am Chlorpromazine 25 given 50mg wrong dosage given.” 16. [...] In an interview, [Staff 1] stated the medication errors were “staff errors.” 23.

From the state's report. Deficiency cited, complaint. Cited: R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that .... "[...]" 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 || child A, B, C, and D were verbally and physically assaulted by staff member A. Following the assault, Staff Member A left the premises to go to MM car and retrieve a loaded handgun and returned to the premises and attempted to engage the residents in fighting outside the building.

From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.c Specific Rights.

On August 15, 2025, the Department received a complaint alleging that staff handled youth(s) in a rough manner.

From the state's report. Substantiated. Cited: 87072(c)(16).

A child in care was physically assaulted by staff member at the operation.

A staff member at the operation performed an inappropriate restraint on a child in care, restricting the child's ability to breathe and causing pain.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.; 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child.

The agency is found in noncompliance when Staff 1 engaged in a physical altercation that involved hitting and pushing Youth A and Youth B. 7 TECHNICAL ASSISTANCE Staff 1 failed to use his radio to call for assistance in this incident.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions..

The facility is found in violation as Staff 1 bit Youth A when Youth A was on top of Staff 1, with her legs wrapped around Staff 1’s neck.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

The facility is found in noncompliance as per video review, Supervisor pushed Youth A.

From the state's report. Violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

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

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

Per interviews, Staff 1, Youth A, Youth B, and Youth D reported Staff 2 choked Youth A while Youth A was lying on her back on the ground and Staff 2 was straddling her. Per interviews, Youth A, Youth D, and Youth F reported Staff 2 hit or attempted to hit Youth A during the altercation.

From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.

A caregiver locked a child in care out of the operation, which resulted in the child kicking the door and breaking it.

From the state's report. Risk level: High. Cited: 748.685(c)(2) - Caregiver responsibility - provide a safe environment.

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.