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.
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..
Provider substantiated for sexual abuse based on the following: Review of camera footage revealed the following: On May 3, 2025, at approximately 9:36am, Individual #1 and Employee #1 entered the cool down/sensory room. Employee #1 and Individual #1 engaged in inappropriate touching, to include Individual grabbing Employee #1's waist band, slapping/smacking Employee #1 on the bottom several times, and Employee #1 grabbing/caressing Individual #1's face. [...] Employee #1 then performed oral sex on Individual #1 three times.
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.. "[...]" marks text left out between sentences.
At the time of the inspection, there was visual evidence of an abusive action, specifically Staff #1 pushing/shoving Resident #1.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-920. (5) The following actions are prohibited: 5. Any action that is humiliating, degrading, or abusive;.
Employee #5 pushed Individual #1 while trying to get the clipboard back. [...] Employee #9 was seen pushing Individual #1 to keep Individual #1 from hitting/kicking them.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-310. B. (3) Required annual retraining: 3. All child care staff shall receive annual retraining on the provider's behavior supports and timeout .... "[...]" marks text left out between sentences.
Individual #1 was placed in a prone restraint that caused bruising and a bloody nose to Individual #1. [...] Based on the provider's investigative finding, there is a preponderance of evidence to support a substantiated finding of physical abuse.
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.. "[...]" marks text left out between sentences.
Employee #1 used unauthorized physical restraint while de-escalating self-harm on Individual #1.
From the state's report. Non-compliance, DBHDS human rights inspection. Cited: 12VAC35-115-110. A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out..
Three staff pushed Individual #1 into the seclusion room, stayed at the door for two minutes, then all three staff walked away.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-960. I. All space in the seclusion room shall be visible through the locked door, either directly or by mirrors.
Per provider's CHRIS report #A20230324, by a preponderance of the evidence which included eyewitness statements, failure to follow policy and witness credibility, the provider substantiated the allegation of neglect when Employee #1 used an improper restraint with Individual #1 which caused Individual #1 to sustain an injury to their arm.
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..
Individual #1 was physically assaulted a second time on 9/22/19 and during that assault there was again only one staff member present with the group of individuals.
The provider failed to report a Level II serious incident involving individual #1 which occurred 9/22/19 in which the individual was physically assaulted. [...] After Individual #1 is physically assaulted, the provider suggests, and offers to put into place, a corrective safety protocol. [...] Another Level II serious incident occurred on 9/22/19 in which Individual #1 was physically assaulted a second time and during that assault there was again only one staff member present with the group patients.
From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-105-150. (5) The provider including its employees, contractors, students, and volunteers shall comply with: 5. The provider's own policies. All ...; 12VAC35-105-160. D. (2) The provider shall collect, maintain, and report or make available to the department the following information: 2. Level II and Level .... "[...]" marks text left out between sentences.
Employee #1 continued to utilize excessive force, causing injury to Resident #1 before a three-person proper restraint was implemented.
Resident #1 was improperly restrained and remained in the care of Employee #1 in lieu of following their plan examples of "What helps me calm down or stay calm" and "What can staff do to help me" as outlined in their behavior support plan.
Employee #2 and Employee #3 arrived in the common area and witnessed Resident #1 being held down in an unapproved restraint.
Employee #1 was seen through video camera footage delivering several excessive and improper restraints towards Individual #1. Employee #1 is seen at one time pushing Individual #1's head into the door during a hold. [...] Use of excessive force when placing a person in physical or mechanical restraint; This regulation was NOT MET as evidenced by: Per the review of video camera footage by the Office of Human Rights Advocate and Office of Licensing Specialist #2 and Employee #3 watched Employee #1 place Individual #1 in an incorrect restraint without intervening.
A review of video footage on 7-25-22 for an incident occurring on 7-21-22 showed that Employee #1 used excessive force during an inappropriate physical altercation with Resident #1. Video footage reviewed on 7-25-22 confirmed that Employee #1 physically assaulted Resident #1 on 7-21-22. Video footage showed that Employee #2 and Employee #3 did not intervene appropriately when they witnessed Employee #1 holding Resident #1 in an inappropriate restraint. Employee #2 and Employee #3 walked around Employee #1 holding Resident #1 in an inappropriate restraint.
From the state's report. Non-compliance, DBHDS investigation; Non-compliance, systemic, DBHDS investigation; Non-compliance, systemic, DBHDS inve. Cited: 12VAC35-46-625. A. (7) The provider shall have and implement written policies and procedures for the on- site provision of a structured program of care or ...; 12VAC35-46-900. A. (3) Within 30 days of admission, the provider shall develop and implement a written behavior support plan that allows the resident to ...; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;; 12VAC35-115-50. B. (2) In receiving all. "[...]" marks text left out between sentences.
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.