Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" 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 March 24, 2026, three clients (C1-C3) ran away from the facility, climbed into dumpsters, and ingested unknown items. Staff called 9-1-1 and took [Child 1] to an emergency room after s/he repeatedly vomited.

From the state's report. Violation cited by DHS. 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.

In plain words: { summary: Six staff members failed to protect a child who had a history of self-harm. The child was found hanging in a bathroom and died by suicide. } Our summary of the state's report. The state's own wording follows.

Based on observation, record reviews and interviews, 6 of 8 audited paraprofessional staff (#1, #2, #4, #5, #6 and #9) failed to protect client from harm and neglect affecting 1 of 1 deceased client ([Deceased client 9]). [...] "She has an extensive history of self-injurious behaviors, suicidal ideation and at least three reported suicide attempts." Review on 3/19/26 of the North Carolina (NC) Incident Response Improvement System (IRIS) revealed: [...] "On March 15, 2026, (Executive Vice President) received a call from Chief Executive Officer (CEO) informing me that a client [Deceased client 9] had attempted suicide at the Cornerstone Treatment Facility (facility). [...] "Staff reported that [Deceased client 9] was found ina bathroom hanging from the shower curtain rod by a ligature. [...] "Based on all information gathered, [Deceased client 9] died as a result of suicide by ligature. [...] "She [Deceased client 9] had previously cut herself a week or two before this incident."

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" 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 inspection, investigative interviews with several clients disclosed a staff member making inappropriate sexual and homophobic remarks.

During the inspection, investigative interviews revealed that a client had eloped from the facility. Upon return, the provider failed to conduct a search of the client who had concealed a box opener on their person and ultimately self harmed with it, cutting their arm and neck.

During the inspection, investigative interviews revealed that a client had swallowed a battery. The provider did not seek immediate medical attention or send the client to the Emergency Room.

From the state's report. Out of compliance, complaint, investigation inspection. Cited: R380-80-6(1)(a)-(i) Client rights; 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.

In plain words: { summary: A child in the program reported that two staff members punched, choked, and spit on her. The program did not suspend the staff members while looking into the claim, and reports to the state registry were delayed. } Our summary of the state's report. The state's own wording follows.

4/23/26 revealed: 3/31/26, Former client (FC) #6 self-injurious behaviors (SIB)/suicidal ideation (SI!) 4/1/26, [Former client 6], SI and elopement 4/2/26, the facility was notified by CPS of client #1's allegation that she was punched and spit on by staff #9 and staff #2 during an incident on 4/15/26, client #4, attempted elopement and jumped out of a moving van 4/16/26, client #1 altercation with peer (client #4) over use of colored pencils; physical altercation between client #1 and client #3; client #1 physical aggression with staff; restrictive intervention due to hitting, spitting on and biting staff (staff #1), and included allegation that staff #1 was abusive and hit client #1 multiple times. [...] One Suicide Attempt, suspect (Former client #6) on scene on 3/31/26. [...] One Physical Assault, suspect on scene on 6/16/26 (client #1). [...] 4/18/26, submitted on 4/21/26, clients #2 and #3 elopement.

"Internal Investigation Summary: On April 2,2026, a social worker (Department of Social Services Investigator) contacted Executive Director [ED/Licensee] and reported that [client #1] alleged she had been physically assaulted by staff (#2 and #9), specifically stating that [staff #2] choked her and [staff #9] punched her in the face An internal investigation was initiated following this report. [...] No documentation of HCPR notification for client #1's allegation that staff #2 and staff #9 "choked and punched client #1 in the face" and spit in client #1's face. [...] "It wasn't until she (client #1) bit me (staff #2) that [staff #9] pinched her (client #1) nose...(client #1) had my arm...[client #1] bit me twice, she had my arm in her mouth until [staff #9] was pinching her (client #1] nose." She and staff #9 were together during the incident, "[Staff #9] never hit her (client #1)."

Had not been suspended nor received any disciplinary action regarding client #1's allegation that staff #2 and #9 choked, punched and spit on client #1. [...] She worked on 3/19/26 and was in the back of the facility with the other clients (#1, #2, #4, #5, and [Former client 6]) during the incident when client #1 alleged that staff #2 and #9 choked, punched and spit on client #1. [...] The ED/Licensee completed the HCPR report for client #1's allegation that staff #2 and #9 choked, punched and spit on client #1.

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 367] 27G .0604 Incident Reporting Requirements; V 132; V 132. "[...]" 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.

"They (staff) put you on 1:1 when you self-harm." [...] Clients were placed on 1:1 "only when you do self-injurious behaviors." [...] "On my 3rd day (1/27/26), there was an incident where [Former client 6] got into the kitchen and grabbed a knife and threatened me. had to remove another client (#5) and took her to [sister facility A] and [Former client 6] cut herself." [...] During an incident on 1/27/26, [Former client 6], who needed 1:1 supervision, was able to obtain a knife and use it to cut herself. [...] Staff #7 left the clients on the van with the Staff #2, who was shadowing, and then later, while [Former client 6] was agitated, left the facility without a backup staff to relieve her.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 315) 27G .1902 Psych. Res. Tx. Facility - Staff. "[...]" 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.

Type of Incident: "suicide attempt, suicide gestures, self-harm, aggression, property damage;" [...] At approximately 1:55 PM, law enforcement arrived and assumed control of the scene. [...] At approximately 2:05 PM, Emergency Medical Services (EMS) arrived. Law enforcement escorted the client to he ambulance. [...] AP arrived at the facility when [Client #1] was getting ready to be transported by EMS to the local hospital on 1/4/26; "She (Executive Director/Licensee) told me to tell the police that the other staff was gone to get something to eat" on 1/4/26;

Psychiatric hospitalization or crisis stabilization admission; [...] On 1/4/24, Staff #1 was at the facility alone with Client #1, when she started to have Cc aggressive behaviors, and inflicted self- harm by cutting herself with glass. [...] EMS transported client to local hospital.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 296] 27G .1704 Residential Tx. Child/Adol - Min.; V 293} 27G .1701 Residential Tx. Child/Adol - Scope. "[...]" marks text left out between sentences.

In plain words: { summary: State reviews showed past facility incidents. These included youth engaging in sexual acts on social media, self-harm, running away, physical fights, hospitalizations for suicide concerns and pregnancy, and crisis center calls. } Our summary of the state's report. The state's own wording follows.

Review on January 14, 2026 at 1:30 p.m. of a list of significant incidents reported by the facility in the previous 36 months to another state entity revealed the following reportable incidents: 1) On 3/30/23, a youth was caught performing sexual acts with men on social media. [...] 3) On 6/20/23, a youth was taken to the hospital for cutting his/her arms and legs. [...] 8) On 9/26/23, a youth ran away from work. [...] 10) On 10/11/23, a youth was taken to the hospital for treatment due to a physical altercation with another youth. [...] 13) On 12/4/23, a youth was taken to the hospital for suicidal thoughts and statements. [...] One youth was taken to the hospital to be checked out due to being pregnant. [...] 22) On 3/24/24, a local crisis center was called due to youth cutting his/herself and swallowing glass. [...] 28) On 6/25/24, a youth was 1013’d for suicide attempt. [...] 42) On 10/21/25, a youth was 1013’d for attempting suicide.

From the state's report. Deficiency cited, severity E, licensure complaint survey. "[...]" marks text left out between sentences.

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.

On August 7, 2025, the client's severe self-harm required transport to the emergency room for treatment and necessitated multiple sutures. Three days later, the client was not adequately supervised and self-harmed again by removing multiple sutures from the prior injury. This incident resulted in a second transport to the emergency room for additional treatment.

During the investigation inspection, the evidence substantiated that on September 17, 2025, a client with a history of significant self-injurious behavior engaged in a serious self-harm incident that resulted in a transport to the emergency room which necessitated over 30 sutures. A second client engaged in self-harm with the same contraband which also resulted in transport to the emergency room and sutures.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(10) Services and supervision to meet each clients needs.

In plain words: A former client refused to be searched, threatened to run away, and left a message claiming abuse. He then walked out, threatened to kill the director and the director's family, and attacked another child in the program. The report also notes two suicide attempts outside the facility. Our summary of the state's report. The state's own wording follows.

Is attempting suicide outside (facility). [...] 7/21/25 4:00pm "...Once arrive to the house (facility) he ([Former client 5]) refused to get searched staff had to ask him repeatedly to get searched it's required staff directed him to go to his room he refused to and grabbed the house and demanded staff to call his social worker or he's running away staff called the social worker number [Former client 5] then left a message stating that he has been rapped and help him he is being molested and demanded help now...([Former client 5]) walked out the door while staff was talking to the other client and demanded staff to give him [Executive Director (ED)]'s address so he([Former client 5]) can go to his (ED) house and kill and take his (ED)whole family out...He ([Former client 5]) then ran to the other client (#2) room door and kicked it open and attacked the other client (#2). [...] 7/12/25, Attempted to hang himself in the backyard of the facility;

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 367|. "[...]" 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 document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" 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 an inspection on 4/28/2025 it was reported that a staff left line of sight supervision of the clients and a client was able to obtain benadryl, which they later ingested with the result of being taken to the hospital.

From the state's report. Out of compliance, investigation inspection. Cited: R380-80-5(10) Services and supervision to meet each clients needs.

Corroborating statements found the facility has had issues with youth using drugs and alcohol while in care, including marijuana, vaping and on July 7, 2024, facility reported a medical emergency as youth was reported to have overdosed on fentanyl. [...] On an isolated incident, the youth was allegedly sexually assaulted by another resident while in care.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

A child was left unsupervised with an unlocked medication cabinet, resulting in the child ingesting a significant amount of medication in a suicide attempt.

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

Findings include: Review on December 9, 2024 at 12:20 p.m. of the Intake Information Form (IIF) for intake GA00181418 revealed that on the night of November 11, 2024, Resident #1 was admitted to the hospital due to ingesting 10 pills. [...] Additionally, Staff C indicated that he/she called 911 and the crisis line, and once the ambulance arrived, Resident #1 stated that he/she had broken into the medication room and took 10 pills.

From the state's report. Deficiency cited, severity G, incident survey. "[...]" marks text left out between sentences.

The operation failed to obtain timely medical care for a child after they ingested over the counter medication during an unauthorized departure.

From the state's report. Risk level: High. Cited: 748.1531(a)(2) - Medical care-A child in care must receive medical care as needed for injury, illness, and pain.

Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. [...] 1. A review of [Resident 1]' s medical record revealed an incident report of a medical overdose by [Resident 1] on September 1, 2024. The report stated "At med pass, [Resident 1] was given [Resident 1] seroquel and [Resident 1] took the bottle, emptied it into [Resident 1] mouth, and swallowed 13 or 14 tablets." The report indicated [Staff 4] contacted 911 and poison control, and [Resident 1] was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of [Resident 1]'s self-injury was not available for review.

The assessment stated [Resident 1] is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a ...; A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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.

In plain words: Medical records showed one child went to the hospital after an injury and was put on meal lockouts and frequent checks. Another child was taken to the emergency room due to self-harm, and the state requested an internal investigation. Our summary of the state's report. The state's own wording follows.

Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. [...] Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1.

From the state's report. Deficiency cited, complaint. Cited: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health .... "[...]" marks text left out between sentences.

For example: 1/2/24 Two youths eloped, stole a vehicle, hit a pole and rolled the vehicle multiple times. 1/28/24 A child eloped and stole clothing and jewelry from Wal-Mart. 1/4/24 A child eloped, stole alcohol, was observed by law enforcement to be intoxicated and trying to break into a house. 1/5/24 A child eloped. 1/6/24 Another child eloped, stole monster drinks and Tylenol from Wal Mart returned to the facility and stated she overdosed on the Tylenol. [...] 3/11/24 A child eloped. 3/11/24 A child eloped and upon return reported she was stabbed, tased and sexually assaulted by a man. 3/12/24 A child eloped. 3/19/24 Three children eloped. 3/20/24 Two children eloped. 3/22/24 Two children eloped together. 3/24/24 Three children eloped together. 3/9/24 A child eloped. 3/31/24 three children eloped, stole alcohol and tested intoxicated. 4/1/24 Four children eloped and stole alcohol. [...] 4/16/24 A child eloped.

From the state's report. Deficiency cited. Cited: 16.04.18.207 QUALITY OF SERVICES. An organization must carry out its licensed programs in an environment that is safe, accessible, and appropriate for the .... "[...]" 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..

In plain words: A former client said two staff members sexually assaulted her while they were trying to get her phone back. The report says there is no documentation of an investigation or of protective measures being put in place. Our summary of the state's report. The state's own wording follows.

No documentation of an investigation into the allegations made by Former Client (FC) #7 that Staff #3 and Staff #4 sexually assaulted her on No documentation to support systems were put MHL0601558 Be WING 01/03/2024 in place to protect clients during an investigation after sexual assault allegations were made against Staff #3 and Staff #4 on 10/20/2023. [...] Description: Client ([Former client 7]) stated that staff (Staff #3 and Staff #4) were sexually assaulting her when staff were trying to get the phone back from the client. [...] Type of incident: Client/Staff Sexual Assault Allegation. Synopsis of incident: On Friday 10/20/2023 Client ([Former client 7]) stole staff phone and ran into her bathroom... and was making statements that staff (Staff #3 and Staff #4) were sexually assaulting her while she was in the bathroom. [...] The allegation of sexual assault incident with [Former client 7] occurred on 10/20/2023.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 132 G.S. 131E-256(G) HCPR-Notification,. "[...]" 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.

As a result, [Child 1] was found unconscious from an overdose and later passed away. [...] As a result, [Child 1] suffered an overdose and loss of life while under the direct care of STRTP [Staff 4]. Pursuant to the Enhanced Civil Penalty law, the Health and Safety Code 1548 (e)(3) states a violation the Department determines "resulted in the death of a person receiving care through a short term residential therapeutic program" the Department will issue an immediate civil penalty of $7,500.00. [...] A copy of this report, the Confidential Names List, and a Civil Penalty Assessment - Serious Bodily Injury/Physical Abuse (Form 421-D) were provided to the administrator.

From the state's report. Deficiency cited at inspection. "[...]" 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 May 22, 2023, Community Care Licensing (CCL) received two allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner. [...] Confidential interviews and medical records note overdose as cause of [Child 1] being found unconscious. [...] Based on confidential interviews and record review the allegations alleging due to a lack of care and supervision minor (Child #1) overdosed while in care and Minor ([Child 1]) did not receive medical treatment in a timely manner are substantiated.

From the state's report. Substantiated. Cited: 87078(a). "[...]" 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.

In plain words: The state found that two staff members, a house manager, and the licensee neglected the needs of two former clients after one reported being sexually assaulted by the other. Staff did not get medical care for the victim and doubted the report. Our summary of the state's report. The state's own wording follows.

Finding #5: Evidence Staff #1, Staff #5, the HM, and the Licensee neglected [Former client 2] and [Former client 3]'s needs after an allegation of sexual abuse made by [Former client 2] against [Former client 3]. [...] "Allegation of sexual abuse reported 9/10 (9/10/23) ...Additional steps of safety plan were taken. [...] No medical care or evaluation completed after an allegation of sexual assault and vaginal penetration with a make-up brush. [...] On 9/9/23 between 9:30 pm and 1:00 am "She [Former client 3] raped me. ..." [...] Reported the sexual assault on 9/10/23 to Staff #1 and Staff #5, "They didn't really believe me." [...] Had [Former client 2] and [Former client 3] write a grievance and spoke to both of them about the alleged sexual assault. [...] Reported the sexual assault grievance made by [Former client 2] to the HM on 9/11/23. [...] On 9/10/23, Sunday, [Former client 2] said to her '[Former client 3] raped' her ... told her she had to talk to [the Licensee] ..."

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.

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" 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.

In turn, [Resident 1] became intoxicated and had to be transported to the local hospital for assessment. [...] 4. In an interview, [Staff 1] acknowledged, as a result, [Resident 1] ingested alcohol, which caused [Resident 1] to be under the influence, where [Resident 1] was transported to the hospital for a medical assessment.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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.

In plain words: A child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

A child in care suffered self-inflicted cuts to her arm on 08/24/2023 and was not seen by a medical professional until 08/28/2023 where the determination was made to admit her into a behavioral hospital for evaluation.

From the state's report. Risk level: High. Cited: 748.125(e)(1)(A) - You must immediately refer a child to a MH professional for a suicide risk assessment if screening finds child to be at a high risk for suicide..

Caregivers were unaware that a child in care, who had history of suicidal gestures, went into the restroom until the door was opened for another child. The child was found unresponsive with clothing around their neck.

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

On 12/20/2022, the Administrator reported an attempted suicide at the facility by [Child 1]. [...] FM Dewalt called 911 as the Administrator Losh and Staff Scholes started CPR. [Child 1] was transported to Saint Joseph's hospital in Stockton then Life-flighted to Oakland Children's Hospital. [...] [Child 1] was pronounced deceased on 12/22/22 at 10:30 pm. [...] The cause of death was listed as suicide by hanging.

From the state's report. Deficiency cited at inspection. "[...]" 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 stated [Resident 3] and [Resident 5] appeared to be "under the influence," as staff questioned [Resident 3] and [Resident 5], it was discovered [Resident 3] and [Resident 5] had ingested eight unprescribed Oxcarbazepine 600 mg capsules each, given to [Resident 3] and [Resident 5] by [Resident 2], who had taken the pills during assistance with the self-administration of medication, without staff noticing. Both [Resident 3] and [Resident 5] were transported to the nearest emergency room location in Maricopa.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... 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 were not aware and accountable of a child's activities when the child was able to obtain a razor and cut themselves seriously enough to where the child required medical attention and had stitches for the injury.

From the state's report. Risk level: High. Cited: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity.

Medication was not kept inaccessible other than employees responsible for storing the medication, as a child was able to obtain 6 bottles of medication and ingested an unknown amount of medication, requiring that child to be hospitalized.

From the state's report. Risk level: High. Cited: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication.

During this investigation it was confirmed staff had an inappropriate relationship with a child in care. This same staff was aware of a child self-harming and did not report to hotline or other staff present to ensure the safety of the child.

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.

The residents returned to the facility and shared pills amongst each other and several residents were rushed to the hospital due to ingestion.

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

In plain words: A child in the program reported having sex with another child in the game room and closet while a staff member sat nearby with their back turned. The report also states that a staff member threw a water bottle and bumped into a child with her body. Our summary of the state's report. The state's own wording follows.

"it would be different staff." Interview on 3/28/22 with client #6 revealed: -had a hickey from her boyfriend; -client #5 was her boyfriend; -had sex with client #5 in the game room; -client #4 was with them; -staff was at the table in front of the entrance to the game room; -staff had their back to them; -had sex twice in the game room closet with client -second time staff were in the same place when she and client #5 had sex; -don't remember what staff was working; -in the closet for five minutes both times. [...] Clients #1, #2, #3, #4, #5 and #6 displayed behaviors which included sexualized behaviors, substance abuse, aggression, self-harm, suicidal ideation, impulsivity, poor boundaries and criminal activity. [...] Staff #3 threw a water bottle and bumped into client #2 with her body.

From the state's report. Deficiency cited, annual and complaint survey, Type A1 violation. Cited: V 293. "[...]" marks text left out between sentences.

In plain words: A child in the program was found asleep in bed with a staff member outside the door. A deputy later took the child to the hospital for an evaluation after a reported suicide attempt using shoelaces tied to a door. Our summary of the state's report. The state's own wording follows.

8:16 pm: "Consumer assessed for 1:1 at 1950 (7:50 pm) - asleep in bed with staff outside door. [County Sheriff's Deputy] arrived at 2016 (8:16 pm) to transport consumer to [hospital] ED (emergency department) for IVC (involuntarily commitment) evaluation. [...] Reason for admission included self harming behaviors, suicidal ideations, physically and verbally aggressive. [...] As a result of those behaviors and attempted suicide attempt (SA), [Former client 13] was IVC'd. nterview on 3/7/22 [Former client 13]'s MCO Care Coordinator stated: [...] On 12/6/21 he received a call at 7 pm froma acility and told [Former client 13] was being sent to the hospital. [...] He recalled being informed during morning rounds that [Former client 13] attempted to hang herself with some shoe laces tied to a door.

From the state's report. Deficiency cited, annual, complaint, and follow-up survey. Cited: V 314. "[...]" 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.

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.

Caretakers at the operation did not provide proper supervision to a child in care allowing for the child to cause a self injury to themselves requiring hospitalization

From the state's report. Risk level: High. Cited: 748.685(a)(4) - Caregiver responsibility - providing the level of supervision necessary to ensure each child's safety and well-being.

In plain words: A staff member denied dragging or touching a child in the program. However, another child stated on a recorded phone call that the staff member dragged and kicked the child. Our summary of the state's report. The state's own wording follows.

RP stated that [Child 1] does at times inflict self-injury but usually does so by biting and the injuries that RP observed did not appear to be self-inflicted. [...] [Staff 1] denied ever dragging or going "hands on" with [Child 1]. [...] Administrator sent IB investigator an audio recording of the phone call between [Staff 4], [Child 2], Administrator where [Child 2] confirms that [Staff 1] dragged [Child 1] up to the steps" and kicked [Child 1].

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.

In plain words: State inspectors found the facility failed to provide proper treatment, keep continuous watch during sleep hours, and follow its licensed capacity limit. The facility also failed to create plans to address behaviors such as running away, sexualized actions, and self-harm. Our summary of the state's report. The state's own wording follows.

Based on observation, interview and record review the facility staff failed to provide intensive, active therapeutic treatment and interventions to ensure safety and to minimize the occurrence of behaviors, failed to assure staff were providing continuous supervision during sleep hours and failed to operate within the scope it was licensed for by admitting a 5th client while it was operating at its licensed capacity of 4 clients affecting 2 of 2 current audited clients (#1 #2), 2 of 2 current unaudited clients (#3 #6) and 2 of 2 former clients ([Former client 4] [Former client 5]). [...] Based on interview and record review, the facility failed to develop and implement strategies and interventions within a treatment plan to address behaviors of elopement, sexualized behaviors and self injury affecting 1 of 2 former clients ([Former client 4]).

From the state's report. Deficiency cited, annual, complaint, and follow-up survey, Type A1 violation. 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.

On December 27, 2020, CCLD received a complaint referral alleging Neglect / Lack of Supervision as Child #1 reportedly had access to hazardous items and [Child 1] ingested hazardous items while in care (see Confidential Names form LIC811, dated 5/28/2021). Information obtained during the investigation including interviews and review of related medical records for [Child 1] indicates in part, numerous hospitalization's for [Child 1] due to ingesting foreign objects and being placed on involuntary psychiatric holds between August 2020 and February 2021. [Child 1] was hospitalized on 12/14/2020, for "foreign body ingestion" of glass. Records indicate [Child 1] ingested two fistfuls of glass shards. On 08/31/2020, [Child 1] was admitted to the hospital emergency room with complaint of swallowing glass and ingesting a metallic screw seen on x-ray. [...] On 10/04/2020, [Child 1] was admitted to the emergency room for ingesting window screws.

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.

Additionally, as had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home as placed in a therapeutic foster home after she was discharged from American Children’s Home abruptly, June 2018. [...] Additionally, HB hes had one hospitalization for self-harm and suicidal ideation prior to placement in a therapeutic foster home. was placed in a therapeutic foster home after she was discharged from American Children's Home abruptly, June Initially, ME cclimated well to her foster family. [...] For recipients identified as high risk for dangerous é or self injurious behaviors the discharge/transition fan includes admission to the appropriate level of care. [...] New behaviors have arisen this month. i had sneaked a railroad spike to the home and started self-harming. [...] 2/19/2019- Recently participated in self-harming behaviors which has led to her be hospitalized.

From the state's report. Deficiency cited, complaint and follow-up survey, Type A1 violation. Cited: V 296 anything management staff will be asked to put. "[...]" marks text left out between sentences.

In plain words: Due to a failure to provide proper staffing and supervision, young people in the program were sexually abused and exploited by a van driver and another man from the community. Our summary of the state's report. The state's own wording follows.

An admission assessment dated 3/9/18 noting “was admitted from a crisis center, Full Scale 1Q of 92, victim of physical, sexual and emotional abuse, witnessed her father being shot and killed by the police, held client and her mom hostage in a standoff, situational drug related incidents such as seizures, mini strokes, panic attacks and blacking out, self-injurious behaviors (picks skin), prior inpatient and outpatient treatment, verbal altercations, issues with being disrespectful and not following rules, destroys property, got high off of Xanax and overdosed (took 21 pills), sniffing cleaning products, AWOL from previous placements, poly-substance abuse (marijuana, alcohol, methamphetamines, over the counter drugs, crack/cocaine, opiates, hallucinogens, barbiturates and inhalants)."

Because of the failure to provide appropriate staffing and supervision, clients were sexually abused and exploited by the Church van driver (CVD) and another non-staff adult male in the community.

From the state's report. Deficiency cited, complaint and follow-up survey. Cited: V 295 27G .1703 Residential Tx. Child/Adol - Reg. for A; V 293.

Furthermore, thel child paychiatic evaluation reeds: “Recently [the child] had cut severe enough that fhe/she] required 27 sutures, [The child] reports [he/she] last cut. [...] The child then swallowed the razor blade. According to notes taken by Staff Member 8, the facility's contractad peychiatriat, Child #1 swallowed the blade because “wea hoping H would kill (hinvher].” The faoilty’s internal policy prohiblis penci] sharpeners In the posseasion of childran or present In the facility at any tins. ‘The factity developed an initial written safely plan on fEEEEhch indicated that Child #1 “will be encouraged to utilize [molding clay, lying down, coloring and humor] to cope with negative feelings.” This written safety plan was not developed with methods fo monitor and prevent self-harm, increased general supervision, or othar adequate methods to ensure child safety.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

In plain words: A child in the program told a staff member about thoughts of self-harm, but the facility did not immediately increase supervision. Later that evening, the child attempted an act of self-harm, and the home then increased supervision. Our summary of the state's report. The state's own wording follows.

" Risk: Miiig#has reported suicidal ideation thalglipouchts to self harm Plan: The Therapist processed coping skills thatllll—has readily available and revised lllMeafety pro! ort Min manag M@@B safety. [...] According to Staff Member A's notes from that session, Child #1 Indicated “continued thoughts of self-harm’. During an interview with representatives of the department, Child #1 also expressed that he/she “had urges and flashbacks and wanted to i wrap sheet around neck"on and also stated that he/she expressed this to Staff Member A during the 15 therapeutic i interaction, ‘The facility did not Immediately implement intensive supervision as part of their intemal safety plan procedure protocol. i At6:14 pm or Chitd #1 attempted an act of self-harm. [...] At 9:10 pm the home implemented Increased supervision due to suicidal ideation and self-harm.

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.142. "[...]" marks text left out between sentences.

On 3/6/2016, Resident #3 self-harmed with a piece of glass he/she reported to have found near the back doors of hallway A of the _ Expressions unit, Resident #3 was sent (o Ohio Vailey Hospital via ambulance where heishe was ‘reated wilh medical glue for an Injury to hisfhes left arm,

From the state's report. Citation, licence action taken. Cited: 55 Pa. Code § 3800.87.a.