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.
Behavior Management: Resident injured during a physical restraint performed by facility staff.
From the state's report. Substantiated complaint. Cited: 340:110-3-154.2(b)(1) behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing ....
A child was injured he had a bruise on his jawline due to a restraint.
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.
The staff initiated a physical restraint after the client threw water on the staff. During the physical restraint, a staff laid on the client's legs, resulting in the client sustaining a fractured foot. <br/>
From the state's report. Out of compliance, complaint, investigation inspection. Cited: 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.
Program staff reported an allegation that a staff member physically abused a resident at the program. Resident A reported to their clinician that Staff F had punched and kicked them and that other staff were rough when restraining them. Staff A confirmed that, while Resident A was in an approved restraint, they observed Staff F punch Resident A a few times, walk around the group of staff and then kick Resident A a few times before leaving the area. Staff C confirmed that they observed Staff F hitting and kicking Resident A repeatedly while Resident A was in an approved restraint conducted by other staff members, and described yelling for other staff to help while shielding Resident A with their body.
From the state's report. Non-compliant, compliance visit. Cited: He-C 4001.22(b)(1) Program staff shall not abuse or neglect residents..
The restraint resulted in the child being injured.
From the state's report. Risk level: High. Cited: 748.2551(b) - EBI Implementation-The caregiver must act to protect the child's safety.
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.
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..
Interviews conducted confirm a staff member yanked client by their hair and forcefully grabbed minor into a restraint to which the client felt like they could not breathe.
From the state's report. Substantiated (one of several allegations). Cited: 87072(c)(16).
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.
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..
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 child in care received a serious physical injury during a restraint.
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.
In plain words: The state found multiple safety and health problems at the program. Issues included privacy violations, medication errors, improper seclusion room use, and many building hazards like mold, broken windows, and unlocked cleaning supplies. Our summary of the state's report. The state's own wording follows.
Compliance issues included HIPPA violation, timeliness of physicals, using a room for seclusion and not following the seclusion use requirements, not meeting the seclusion room physical requirements, seclusion room documentation, and medication errors resulting in a child receiving the wrong dosage.Maintenance concerns with some, needing to be addressed with expeditious correction to mitigate the risk for harm or injury, included: a broken window, mold in a bathroom ceiling and rafters, cluttered laundry room, missing door jams with nails protruding, sharp metal pieces in a window sill, cleaning supplies and other hazardous items in an unlocked closet due to locks not working, missing smoke detectors, laundry stacked against a gas water heater, bathroom door with only one hinge causing the door to not open/close/swing properly, missing floor vents, missing cabinet faces in the kitchen, an oven door that does not close completely, a loose doorknob in the bathroom, significant peeling paint in the bathroom, excessive holes in the walls throughout the house, wires protruding from a removed thermostat, sticker type weeds in the yard, a partially removed window well grate cover.
From the state's report. Deficiency cited, provisional license. Cited: 16.04.18.102.04 DISPOSITION OF APPLICATIONS. 04. Provisional License. A provisional license may be issued to an organization when a licensing standard is not ....
In plain words: A complainant said a resident had scratches and bruises and was told by a staff member that the resident was in PCM restraints. A licensing coordinator reviewed video of the resident and a staff member in the calming space and found the techniques used did not follow the program’s PCM curriculum. Our summary of the state's report. The state's own wording follows.
The complainant stated that they observed scratches and bruises on Resident A, and that upon inquiring with program staff, the complainant was informed that Resident A is placed in "P[C]M restraints." The licensing coordinator reviewed video footage of the resident and staff in the Calming Space, which showed behavior management techniques being used that were not compliant with the Professional Crisis Management (PCM) curriculum utilized by the program.
From the state's report. Non-compliant, complaint visit. Cited: He-C 4001.22(g) Restraint techniques used shall be consistent with the curriculum required in (f) above and be reviewed at least annually with program staff to ....
Based on confidential interviews and documents reviewed, the preponderance of evidence standard has been met and the allegations that staff restrained minor, resulting in minor sustaining bruises, Staff hit minor, and Staff do not provide a safe environment for minor is substantiated.
From the state's report. Substantiated (one of several allegations).
The confidential witness continued stating that staff observed bruising on [Child 1]'s neck an hour after the restraint. [...] Another confidential interview disclosed that after the restraint [Child 1] had marks on the neck.
From the state's report. Substantiated. Cited: 84072(d)(19). "[...]" 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 revealed that Child #1 was assessed by Staff D and alleged obtaining injuries because of the restraint. [...] (4) A review on April 1, 2025, at approximately 1:49pm of video footage from March 6, 2025 revealed Staff B shove Child #1 on two separate occasions prior to Child #1 assaulting Staff B in retaliation. [...] Staff B is observed interacting with Child #1, who then turns his/her back to walk away and at this moment Staff B is observed shoving Child #1. [...] Based on video footage of the incident, Staff B is observed using corporal punishment, by pushing Child #1 on two occasions.
From the state's report. Deficiency cited, severity D, incident, licensure complaint survey. "[...]" marks text left out between sentences.
Following an attempted improper restraint video footage shows Staff 1 and Youth A struggling over the logbook resulting in Youth A’s injury.
From the state's report. Repeat violation established, special investigation. Cited: CCI Rule 400.4158 Intervention standards and prohibitions.
While on site for interviews on 6/24/2025, it was reported that during a restraint, a staff member placed their hands on the neck of a client and proceeded to squeeze with enough force to leave a red mark on the client’s neck afterwards.
From the state's report. Out of compliance, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
On child A did not receive the appropriate medical treatment or evaluation for injuries received during the restraint on . Child A did not receive medical attention until days after the tape review, when a child abuse report was also called into the hotline on the same day. Child A did not receive medical attention until January 28, despite staff person A's assertions that all children were medically assessed on the day of the incident.
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 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.
On child A did not receive the appropriate dental treatment needed for Child A was involved in a restraint resulting in both of upper front teeth being broken off, exposing the root in . The child was not taken to the dentist immediately following the incident.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.k Specific Rights.
During an investigation inspection, the investigator discovered that during a restraint on April 13, 2025, a staff member, through physical contact with the client, caused an injury to a client's face.
From the state's report. Out of compliance, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights.
Additional Non-Compliance Found During Investigation: Behavior Management: Staff members used excessive force and prohibited behavior management actions in dealing with a resident's behaviors.
Behavior Management: Staff used improper restraint techniques, causing significant bruising to a resident.
From the state's report. Found during a substantiated complaint investigation; Substantiated complaint. Cited: 340:110-3-154.2(b)(1) behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing ...; 340:110-3-154.2(d) Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have ....
The complaint alleged staff restrained a minor resulting in injuries and staff handled minor in a rough manner. Based on confidential interviews and records review, it was found that on February 3, [Staff 1] and [Child 1] (see LIC811 dated 4/16/25) were involved in a physical struggle which led to the client being restraint inappropriately on their bed and staff handling the minor in a rough manner, which resulted in [Child 1] obtaining bruising by their neck. (LIC9099-C dated 4/16/25) The preponderance of evidence standard has been met, and therefore the above allegations staff restrained a minor resulting in injuries and staff handled minor in a rough manner are found to be SUBSTANTIATED.
From the state's report. Substantiated (one of several allegations). Cited: 87022(f), 87072(c)(16). 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.
A child in care incurred injuries during a restraint.
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.
A child in care was seriously bruised from a restraint conducted by a caregiver.
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.
Child received an injury to the face after an inappropriate restraint.
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..
Any injuries resulting from the use of restraint and seclusion procedures; c.
From the state's report. Violation cited by DHS.
Child in care was injured during an unnecessary restraint when excessive physical force was used.
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.
At approximately 9:35 AM, via video in hallway footage, two male staff members were seen dragging Client #1 from the seclusion room holding the client under both arms, two female staff members were following.
A review of the emergency safety intervention justification packet dated 08/11/2024 at 1715 [5:15 PM] with a physical and chemical restraint safety intervention implemented revealed Client #3 received an injury due to improper technique of the applied physical restraint. [...] Client #3 during the video review of the emergency safety intervention, it revealed client was pulled from the melee at 5:21 PM and placed into a physical restraint, then received a chemical restraint at Client #3 was interviewed on 8/28/24 1:21 PM and indicated an injury to the right side of the head that occurred during the emergency safety intervention.
From the state's report. Deficiency cited, complaint survey. Cited: N 126 PROTECTION OF RESIDENTS N 126; N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
On , child A was mistreated by staff member A. Staff member A inappropriately restrained child A resulting in a scratch on child A face.
On , child A was placed in a restrictive procedure that was used as a program substitution to restrain Child A. Staff member A inappropriately restrained child A resulting in a scratch on child A face.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.b Specific Rights; 55 Pa. Code § 3800.202.a Appropriate Use of Restrictive Procedures.
Any injuries resulting from the use of restraint and seclusion procedures; c.
From the state's report. Violation cited by DHS.
It is alleged that on July 8", 2024, an organization's staff, used an unapproved physical restraint technique, resulting ina physical strike to the youth, causing a Aliegation: bruise.
From the state's report. Evidence supports non-compliance, DFS notice. Cited: Chapter 3, Section 25 Emergency Safety Intervention; Chapter 3, Section 23 Child and Family (Parent, Guardian) Rights; Chapter 3, Section 24 Disciptine.
While a child was being restrained by staff, another staff choked the child.
A staff threw away a child's food in response to the child spitting at their feet.
A child received a bloody, swollen nose during a restraint due to a staff member banging their head on the ground.
From the state's report. Risk level: High. Cited: 748.2461(b)(3) - Short Personal Restraint-Caregiver may not use restraint that obstructs child's airways or impairs child's breathing; 748.2307(14) - Other Prohibited Punishments-withholding food that meets the child's nutritional requirements; 748.2461(a)(2) - Short Personal Restraint-Caregiver must use minimal amount of reasonable and necessary physical force.
Received pictures the night of 1/11/24 "showing Cc Cc marks on his ([Former client 2]'s) neck ...think they were obtained during the restraint;"
From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 512. 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 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.
A staff member hit a child in the face as a means to get the child to comply.
Collateral staff confirmed during interviews that the staff member was directed to release the child from the restraint and the child said they could not breathe.
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.; 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso.
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 ....
On , Child A was involved in 3 restraints in which they sustained injuries and was not medically assessed until the following day.
From the state's report. Citation, complaint inspection. Cited: 55 Pa. Code § 3800.32.k Specific Rights.
It was found during the investigation that a child in care received significant bruising to their shoulder after a short personal restraint.
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.
Based on LPA's observations, record review, and interviews, a resident in care sustained bruising on their arm following an improper restraint performed by staff.
From the state's report. Substantiated.
Resident reported small abrasion on her palm side next to her thumb from the restraint, petechiae around her eyes and cheeks that were not observed on 10/25/2023. [...] I did not get up as I was eating dinner. [QBHP #1] took her to the seclusion room and called me to take his place. [Client #1] was kicking, screaming, scratching, drew blood from my hand from scratches, and banging her head. [RN #1] brought a pillow.
The Policy "Use of Seclusion-Intensive Residential" (Reviewed 07/24/2023), read in part, "...Seclusion is utilized to protect the patient from injuring self or others...
From the state's report. Deficiency cited, complaint survey. Cited: N 132 PROTECTION OF RESIDENTS N 132; N 172 MONITORING DURING AND AFTER N 172. "[...]" marks text left out between sentences.
In plain words: A report noted several serious incidents in the program, including a medical emergency from suspected drug use, aggressive physical restraints by staff that caused injuries, sexual misconduct, criminal activity, and a child leaving without permission. Our summary of the state's report. The state's own wording follows.
These incidents included a client medical emergency as a result of reportedly smoking methamphetamine, an unnecessary and aggressive physical restraint that resulted in serious client injury, a physical restraint in which a staff punched a client in the face multiple times that resulted in client injury, 5 incidents of client sexual misconduct, criminal activity, and an AWOL incident.
From the state's report. Out of compliance, complaint, focus inspection. Cited: R501-1-11(2)(a)-(f) Licensed Program Complaints and Critical Incidents.
The evidence substantiated that a staff member bit a client during a physical restraint incident in response to the client aggressively engaging with the staff; the client incurred an injury as a result.
From the state's report. Out of compliance, focus inspection. Cited: R495-876-5(1)(a)-(m) Code of conduct.
On April 4, 2023, Community Care Licensing (CCL) received the allegation that facility staff handled minor in a rough manner and facility staff inappropriately restrained minor causing injury. [...] Based on confidential interviews and document review, the allegations that facility staff handled [Child 1] in a rough manner and facility staff inappropriately restrained [Child 1] causing injury are SUBSTANTIATED because the preponderance of evidence has been met.
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.
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..
During a short personal restraint a child received carpet burn to his face and his elbow.
From the state's report. Risk level: High. Cited: 748.2461(a)(1) - Short Personal Restraint-Caregiver must minimize risk of physical discomfort, harm, or pain to child.
In an investigation conducted by DFPS, two staff were found reason to believe for physical abuse of a child.
Staff was observed via the EBI video, using excessive force when he lifted the child off of the ground during a restraint, causing the child's feet to drag; consequently, causing both child and staff to fall to the ground and injuring the child's foot.
From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.
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.