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.
It was found during the investigation a child sustained injuries as the result of an improper restraint.
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.
Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.
Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.
From the state's report. Risk level: High. Cited: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso; 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.
On 8/31/ 21, CCLD received an allegation reporting that on 08/29/21, [Staff 1] physically restrained [Child 1] causing injuries to [Child 1]'s neck area and possible rib fracture. Licensing Program Analyst (LPA), Regina Martin investigated the complaint allegation and based on information obtained, the preponderance of the evidence standard has been met, the allegation of physical abuse was substantiated.
From the state's report. Substantiated (one of several allegations). 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.
Page The Department received a complaint alleging a client was injured during an altercation with staff and staff restrained a minor. [...] In addition to the above information, the investigation revealed staff admitted to law enforcement that a client was restrained during the incident and informed a placing agency investigator the restraint took place on the floor. [...] Record review and confidential interviews corroborated a client sustained an injury to his cheek after being restrained in a prone position.
From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" marks text left out between sentences.
Staff interviews reveal that staff handled client in a rough manner while performing a one-man restraint causing the client injuries.
From the state's report. Substantiated. Cited: 87072(d)(11).
A tenured campus supervisor was observed on video utilizing inappropriate restraint techniques and physical force against a child resulting in multiple injuries to the child's face, wrist, torso, and back of head.
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.
After the restraint, the was observed with scratches on her face and bruising on her wrist and was later taken to the doctor for complaints of pain in her chest and arms.
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.
On page 346 it states, "The restraints must not cause injury to the child." LPA Diaz was able to identify five nail marks on client's right forearm.
From the state's report. Substantiated.
On 08/31/2022, Community Care Licensing (CCL) received an allegation that [Child 1] was injured by staff due to excessive restraint. It was reported that [Staff 1] restrained [Child 1], when [Child 1] attempted to leave the facility and pushed and tussled with [Child 1], resulting in bruises on [Child 1]'s legs. [...] Based on confidential interviews and a review of the gym video footage, the allegation that [Child 1] was injured by staff due to excessive restraint is substantiated.
From the state's report. Substantiated. Cited: 84072(d)(11). "[...]" 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.
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 report obtained by law enforcement reflects that BOD and the minor sustained bodily injuries due to an unauthorized restraint initiated by BOD.
From the state's report. Substantiated.
In plain words: A child in the program received a head injury during a physical restraint. The facility failed to make sure the restraint did not cause the injury, and the child was sent to the emergency room for a scan. Our summary of the state's report. The state's own wording follows.
Based on record review, the facility failed to ensure a physical restraint did not result in injury for 1 (Client #1) of 1 sampled client who received a head injury during a physical restraint. [...] 6. List any revisions for the resident's plan of care, treatment, or services: Sent to ER [Emergency Room] [Hospital]...Description of injuries: R had silver dollar size hematoma on R [right] lower occipital lobe @ [at] base; Description of Treatment: APRN [Advanced Practice Registered Nurse] notified resident sent to [Hospital] for CT [computed tomography] scan of head..." b.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
A youth in care was injured in the face during an attempt of a restraint by a staff member.
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: A former client reported to a school counselor that the chief executive officer was too rough during a physical hold. The report stated this caused bruises on the arms and legs and pain in the head and buttocks. Our summary of the state's report. The state's own wording follows.
An investigation had been completed this month (July 2022) regarding a client (former client (FC) #2) who made an allegation that the Chief Executive Officer/Qualified Professional (CEO/QP) physically abused him; [Former client 2] had reported to his school counselor (5/27/22) that the CEO/QP was too rough when he restrained him which resulted in bruises on his arms and legs and pain in his head and buttocks.
From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 132. 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 course of this investigation, it was determined that a staff member conducted an unnecessary EBI and used unnecessary strength forcing a child in care to the ground causing a bruise on their 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.
A child in care was inappropriately restrained leading to injuries.
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.
A staff members actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.
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.
A staff members actions were noted to have presented a genuine threat of substantial harm from physical injury to the child when the staff member placed the child in an inappropriate restraint.
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.
It is alleged that staff became physically aggressive with a child in care and executed an improper and unwarranted restraint on the child in care which resulted in an injury.
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.
LPA confirmed through interviews with staff and clients and record reviews that the client's injury was caused by the manual restraint. Based on the information obtained, there is a preponderance of the evidence to prove that staff violated the client's personal rights by causing injury due to a manual restraint.
From the state's report. Substantiated.
Client #1 revealed: "Friday (10/8/21) at around dinner time ...staff (Staff #2) pushed me into the corner of the room under a shelf near window (back right corner) ...I attempted to go in another direction ...staff ...bent wrist in the process to stop client assault. [...] Was working light duty after sustaining an injury in a restraint;
From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. Cited: V 512. "[...]" marks text left out between sentences.
An IR (Incident Report) Narrative dated 10/24/21 documented, "...Time: 03:30 [3:30] PM; Patient Status: Personal Restraint; Intervention Description or Observation Narrative: While staff was performing a restraint pt [patient] began scratching a staff member and head-butting them.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 132 PROTECTION OF RESIDENTS N 132.
In plain words: A staff member placed a client in physical, chemical and seclusion restraints after the client became verbally and physically aggressive, kicked doors, tried to leave the building and self‑harmed. The client was injured, receiving bruises, and the incident was recorded in multiple reports. Our summary of the state's report. The state's own wording follows.
restraint/seclusion, not in terms of Based on interview and record review, the facility practicing techniques, but with regard to failed to ensure no injury occurred during a which techniques are approved, when to physical restraint for 3 (Clients #5, #7, and #9) of use restraint/seclusion or not use it 12 (Clients #1-#12) sampled clients who had and the emphasis on avoiding injuries to documented use of restraints and or seclusion. clients and staff and avoiding restraint The findings are: whenever possible. [...] Staff was able to keep client and peer from making it out of the building but client became very physically aggressive with staff, punching them, pushing them, being verbally aggressive. [...] At 1:19:23, the client kicked door and walked down the hallway with four staff following him, pacing with his head down, kicking doors.
Staff pushed, then grabbed the client and drug to the door, then placed Client #7 in a hold at the door. [...] Client and peer used laundry basket to break light covers and used pieces to self-harm with ...1. [...] Client then started kicking doors open in an attempt to elope ...1.
Client then was trying to elope by kicking doors around the unit. [...] Client threw staff phone on the floor and while staff attempted a restraint client hit and grabbed at staff until being place in a restraint." 2.) An Incident Report Packet dated 4/11/21 by BI #4 documented, "...client became verbally aggressive with staff. [...] Once client entered room she began to self-harm.
This will be effective as that caused the injuries and developed and of 9-12-21. implemented a plan to prevent further potential injuries for 1 (Client and #9) 3 (Clients #5, #7 and #9) sampled clients who received an injury during a personal restraint. [...] At 1:19:23, the client kicked a door and walked down the hallway with four staff following him, pacing with his head down, kicking doors. [...] On 8/13/21, at 9:05 a.m., Registered Nurse (RN) #2 was asked, "How did [Client #9] get injured during a restraint on 7/27?" She stated, "He's a very aggressive, big child. He was attacking staff, and staff had to put him in a restraint, and he was taken to the floor and he got bruising.
A Seclusion and Restraint Form dated 4/12/21, documented, "Date and Time Initiated; 4/12/2021 7:21 AM; Date and Time Ended: 4/12/21 8:20 AM...Behavior demonstrated to justify use of procedure: Physically and verbally aggressive with staff, kicking doors, attempting to elope, property damage...Beginning Time: 7:23 AM; Procedure: Seclusion...Client Behavior: Combative, Cursing...Beginning Time : 7:32 AM; Procedure: Chemical Restraint; Location: Seclusion Room;...Client Behavior: Cursing..." A Report To Quality Assurance dated 4/12/21 documented, "...he began kicking doors and being non-compliant, client was asked by staff to stop but he continued until he kicked and broke one of the doors, the nurse was notified and from there client was placed in seclusion and given a chemical..." A Behavioral Intervention Observation Log dated 4/12/21 documented, "...Time 7:23 am; Procedure: 3 (Seclusion); ...Client Behavior: 2 (Calm)...Time: 7:32 am; Procedure: 4 (Chemical);...Client Behavior: 2...Time: 7:33 am; Procedure: 4...Client Behavior: 2...Time: 7:48; Procedure: 3 (Seclusion)...Client Behavior: 2...Time 8:03 am; Procedure: 3...Client Behavior: 2...8:03 am; Procedure: 3...Client Behavior: 2...8:18 am; Procedure: 3...Client Behavior: 2...8:20 am; Procedure: 3...Client Behavior: 2...release from procedure ...." Documentation indicated the client was calm at the time he was placed in seclusion, was calm at the time of the administration of the chemical restraint in the seclusion room and remained calm for 57 minutes before he was released. b.
A Seclusion and Restraint Form dated 6/21/21 documented, "...Aggressive with staff and kicking open unit doors attempting to elope... [...] Self-Inflicted... [...] The Seclusion and Restraint form dated 5/12/21 at 10:02 a.m. documented, "...kicking unit doors, self-harming, physically aggressive with staff..." RN #2 was documented as participating in the ESI for Client #3 but was not listed as participating in the Client Debriefing.
From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128; N 140 ORDERS FOR USE OF RESTRAINT OR N 140 Upon review of these identified issues, it is; N 149 ORDERS FOR USE OF RESTRAINT OR N 149; N 202 MEDICAL TREATMENT FOR INJURIES N 202 This deficiency has the potential to impact 9-15-21; N 130 PROTECTION OF RESIDENTS N 130 This deficiency has the potential to impact; N 188 POST INTERVENTION DEBRIEFINGS N 188 This deficiency has the potential to impact 9-15-21. "[...]" marks text left out between sentences.
Staff grabbed a resident forcefully causing the resident to fall forward into a window, with his face pressed into a mat.
A staff inappropriately restrained a 16 year old resident, resulting in an injury to the head.
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; 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.
A caregiver used excessive force during a restraint, causing substantial physical injury to a child.
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 substantiated a complaint that the facility failed to prevent an injury during a physical restraint. A staff member stated that a nurse failed to have a registered nurse check the injury and did not report it until the next day. Our summary of the state's report. The state's own wording follows.
Complaint #AR00023871 was substantiated, all or in part, with these findings Based on record review and interview the facility Cc 041115 oo 12/10/2019 failed to ensure an injury did not occur during the use of a physical restraint for 1 (Residet #1) of 1 sampled resident who was physically restrained. [...] She stated, "The nurse that was on duty did not get the RN [Registered Nurse] to do a face-to-face and didn't report the injury until the next day..." CFR(s): 483.362(a) Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and Cc the safe use of restraint throughout the duration of the emergency safety intervention.
From the state's report. Deficiency cited, complaint survey. Cited: N145.. "[...]" marks text left out between sentences.
My therapist was in the hall and called for help. [PT #1] came and put me in a restraint." She was asked, "Did you get injured during the restraint?" She stated, "No." She was asked, "Who was present when this incident occurred?" She stated, "I don't think anyone saw the whole thing, cause she [PT #}) told them to get out of the room." c.
From the state's report. Deficiency cited, complaint survey.
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.
(1719) [5:19 p.m.] pt being sent to ER [emergency room] for evaluation of pain to R shoulder..." d. [...] Then he started to try to count to ten and started to bite one of them and I told him don't bite, don't bite." RN #1 and LPN #1 were asked, "Was he fighting?" LPN #1 stated, "He was trying to come up with his body and his legs were coming out of the restraint, so just kinda wiggle wormed." RN #1 and LPN #1 were asked, "Is bruising normal during a restraint?" LPN #1 stated, "You can get some bruising right there in the crease [indicating crease between the junction of the upper arm and shoulder], that is pretty normal, but not to that extent." Both RN #1 and LPN #1] stated, "Not to that extent." RN #[ and LPN #1 were asked, "Was it caused by undo pressure on his shoulder?" LPN #1 stated, "Yeah, I never seen a restraint look like that." e.
From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.
The resident was placed into a physical restraint in released from the physical restraint at 8:34 p.m. The form documented a physical assessment was completed by Registered Nurse (RN) #1 on 4/26/19 at 8:34 p.m. The assessment documented Resident #1 had an injury during restraints: "c/o [complained of] left knee pain-good ROM [range of motion] [no] swelling...
From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128.
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.
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.
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.
ont Child # 1 received treatment at Sacred Heart ER for a head injury and forehead laceration stemming from a manual restraint Initiated by Staff Member A. Child #1 had a 1 cm linear laceration in a oblique placement in the center of his/her forehead, resulting from Child # 4 hitting his/her head off of a wall during the restraint.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
In plain words: A staff member restrained a child, causing a circular abrasion on the forehead, abrasions on the cheek, a reddened area under the eye, neck scratches and abrasions, and a large abrasion with petechiae on the right shoulder blade. Our summary of the state's report. The state's own wording follows.
According to the facility's documentation, the restraint resulted in Child # 1 sustaining an abrasion at the midline of his/her forehead, a 2cm circular abrasion and a 4cm linear abrasion to the left cheek, a sialt redenned area under the left eye, two 2cm abrasions to the loft side of his/her neck, a linear scratch to the midline of hisMer neck, and a 3 inch abrasion with petechiae surrounding the area on his/her right shoulder blade and 2 linear abrasions,
According to tho facilily's documentatlon, the restraint resulted in Child ## 1 sustaining an abrasion al the midline of his/her forehead, a 20m circular abrasion and a dem linear abrasion to the left cheek, a small sedenned area under the left aye, {wo 2cm abrasions to the left side of his/her neck, a linear scratch to the midline of hisfhor neck, and @ 3 inch abrasion with petechiae surrounding the area on his/her right shoulder blade and 2 linear abraslons.
From the state's report. Citation, incident inspection. Cited: 55 Pa. Code § 3800.32.b; 55 Pa. Code § 3800.202.b.
In plain words: A staff member physically held a child to the floor of a bedroom after the child yelled and got close to the staff member. The child complained of arm pain afterward, went to the hospital, and was diagnosed with a broken arm. Our summary of the state's report. The state's own wording follows.
On 7/6/15 al approximately 8:30 AM, Staff Member A manually restrained Resident # 4 {o the floor In a resident bedroom for yalling and getting Into the face of the staff member, Following the restraint, Resident # 4 complained of left arm discomfort and was transported to a hospital emergency room and was diagnosed wilh a radial shaft fracture to his/her left arm.
From the state's report. Citation, complaint, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
In plain words: During a physical hold, a staff member pressed an elbow against a child's throat and made it hard for the child to breathe. The child was left with scrapes and needed an inhaler after the incident. Our summary of the state's report. The state's own wording follows.
Duzing the manual restraint, Staff Person A had his/her elbow pressed against Resident #1’s throat, which applied pressure to the resident's respiratory system and restricted the resident's breathing, A physical evaluation form, dated 10/27/13 at 6:25 p.m., indicated Resident #1 had abrasions on the right front of the neck, abrasions on the right collar bons, abrasions on the right shoulder, and that the resident required administration of Ventolin, an inhaler, following the manual restraint.
From the state's report. Citation, interim, incident inspection. Cited: 55 Pa. Code § 3800.32.b.
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.
(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.
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.