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.

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: 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 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.