Severe reports

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.

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: 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.

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.

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.

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: 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: 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.

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.