New Life Childrens Treatment Center

During a review conducted on February 20, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2026-02-21

During a review conducted on February 20, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2026-02-21

During a review conducted on February 20, 2026, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation is now unable to successfully move to post-plan monitoring. Furthermore, your operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring, including having an open investigation(s). Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2026-02-21

During a review conducted on August 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 6, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on June 6, 2025. Specifically, the operation was cited for 748.685(a)(4): Caregiver responsibility - During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 7/10/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-08-20

During a review conducted on August 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 6, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on June 6, 2025. Specifically, the operation was cited for 748.685(a)(4): Caregiver responsibility - During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 7/10/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-08-20

During a review conducted on August 19, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 6, 2025, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received a high weighted citation in a pattern/trend category on June 6, 2025. Specifically, the operation was cited for 748.685(a)(4): Caregiver responsibility - During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 7/10/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-08-20

Suicide screening that was provided was denied to have been completed by staff and child in care.

Resolution: Corrected: 2025-07-31

Suicide screening was not completed immediately after child in care was found with a t-shirt around their neck.

Resolution: Corrected: 2025-07-31

Suicide screening that was provided was denied to have been completed by staff and child in care.

Resolution: Corrected: 2025-07-31

Suicide screening that was provided was denied to have been completed by staff and child in care.

Resolution: Corrected: 2025-07-31

Suicide screening was not completed immediately after child in care was found with a t-shirt around their neck.

Resolution: Corrected: 2025-07-31

Suicide screening was not completed immediately after child in care was found with a t-shirt around their neck.

Resolution: Corrected: 2025-07-31

The medication count was documented incorrectly on the med log for a child s prescribed medication.

Resolution: Corrected: 2025-05-27

The medication count was documented incorrectly on the med log for a child s prescribed medication.

Resolution: Corrected: 2025-05-27

The medication count was documented incorrectly on the med log for a child s prescribed medication.

Resolution: Corrected: 2025-05-27

During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift.

Resolution: Corrected: 2025-07-10

During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift.

Resolution: Corrected: 2025-07-10

During DFPS investigation staff reported having earphones on and admitted to having their eyes closed while working the overnight shift.

Resolution: Corrected: 2025-07-10

A child in care, with identified high risk behaviors, was not provided 15-minute wellness checks and was left alone in the residence by a staff member.

Resolution: Corrected: 2025-06-13

A child in care, with identified high risk behaviors, was not provided 15-minute wellness checks and was left alone in the residence by a staff member.

Resolution: Corrected: 2025-06-13

A child in care, with identified high risk behaviors, was not provided 15-minute wellness checks and was left alone in the residence by a staff member.

Resolution: Corrected: 2025-06-13

The Administrator's position has been vacant for more than 60 days.

Resolution: Corrected: 2025-04-04

The Administrator's position has been vacant for more than 60 days.

Resolution: Corrected: 2025-04-04

The Administrator's position has been vacant for more than 60 days.

Resolution: Corrected: 2025-04-04

Fire extinguisher are NOT being inspected monthly.

Resolution: Corrected: 2025-03-17

Fire extinguisher are NOT being inspected monthly.

Resolution: Corrected: 2025-03-17

Fire extinguisher are NOT being inspected monthly.

Resolution: Corrected: 2025-03-17

During a review conducted on February 13, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 16th, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received high weighted citation in a pattern/trend category on December 16, 2024. Specifically, the operation was cited for 748.685(a)(3): Caregiver responsibility - Child in care was left unsupervised inside the dorm. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 1/01/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-02-14

During a review conducted on February 13, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 16th, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received high weighted citation in a pattern/trend category on December 16, 2024. Specifically, the operation was cited for 748.685(a)(3): Caregiver responsibility - Child in care was left unsupervised inside the dorm. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 1/01/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-02-14

During a review conducted on February 13, 2025, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plan for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring.? As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plan, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on December 16th, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the administrator?s failure to ensure compliance include the following: Your operation received high weighted citation in a pattern/trend category on December 16, 2024. Specifically, the operation was cited for 748.685(a)(3): Caregiver responsibility - Child in care was left unsupervised inside the dorm. The purpose of this standard is to protect the health, safety, and well-being of children by ensuring adequate supervision. Supervision is a basic element to the prevention of harm. The operation met compliance on 1/01/2025. - Operation failed to satisfy the conditions of the plan. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring. - Operation was unable to meet compliance with high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plan.

Resolution: Corrected: 2025-02-14

It was confirmed that a staff member gave gifts to a child and showed them preferential treatment.

Resolution: Corrected: 2025-03-04

Caregivers and children provided corroborating information that a staff member behaved inappropriately with children in care.

Resolution: Corrected: 2025-03-04

It was confirmed that a staff member gave gifts to a child and showed them preferential treatment.

Resolution: Corrected: 2025-03-04

Caregivers and children provided corroborating information that a staff member behaved inappropriately with children in care.

Resolution: Corrected: 2025-03-04

Caregivers and children provided corroborating information that a staff member behaved inappropriately with children in care.

Resolution: Corrected: 2025-03-04

It was confirmed that a staff member gave gifts to a child and showed them preferential treatment.

Resolution: Corrected: 2025-03-04

On video, a staff member was seen shoving a child to prevent them from going into the room of a peer.

Resolution: Corrected: 2025-02-17

On video, a staff member was seen shoving a child to prevent them from going into the room of a peer.

Resolution: Corrected: 2025-02-17

On video, a staff member was seen shoving a child to prevent them from going into the room of a peer.

Resolution: Corrected: 2025-02-17

Child in care was left unsupervised inside the dorm.

Resolution: Corrected: 2024-12-23

Child in care was left unsupervised inside the dorm.

Resolution: Corrected: 2024-12-23

Child in care was left unsupervised inside the dorm.

Resolution: Corrected: 2024-12-23

The operation did not report a diagnosed communicable disease to licensing.

Resolution: Corrected: 2024-11-13

The operation did not report a diagnosed communicable disease to licensing.

Resolution: Corrected: 2024-11-13

The operation did not report a diagnosed communicable disease to licensing.

Resolution: Corrected: 2024-11-13

During a review conducted on August 12, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 03, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium high weighted citation in a pattern/trend category on June 03, 2024. Specifically, the operation was cited for 748.125(d)3: Suicide Screening - Document that any person conducting a suicide screening meets the conditions and training requirements. Compliance of deficiency was met on July 02, 2024. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with medium high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-08-13

During a review conducted on August 12, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 03, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium high weighted citation in a pattern/trend category on June 03, 2024. Specifically, the operation was cited for 748.125(d)3: Suicide Screening - Document that any person conducting a suicide screening meets the conditions and training requirements. Compliance of deficiency was met on July 02, 2024. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with medium high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-08-13

During a review conducted on August 12, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on June 03, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium high weighted citation in a pattern/trend category on June 03, 2024. Specifically, the operation was cited for 748.125(d)3: Suicide Screening - Document that any person conducting a suicide screening meets the conditions and training requirements. Compliance of deficiency was met on July 02, 2024. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with medium high weighted licensing citation. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-08-13

The operation provided an intake suicide screening tool used at admission on a child in care with no documentation of the personnel who administered the tool having the training to do so.

Resolution: Corrected: 2024-06-17

The operation provided an intake suicide screening tool used at admission on a child in care with no documentation of the personnel who administered the tool having the training to do so.

Resolution: Corrected: 2024-06-17

The operation provided an intake suicide screening tool used at admission on a child in care with no documentation of the personnel who administered the tool having the training to do so.

Resolution: Corrected: 2024-06-17

A child in care did not receive medical treatment for a fracture until two days after their injury.

Resolution: Corrected: 2024-07-12

A child in care did not receive medical treatment for a fracture until two days after their injury.

Resolution: Corrected: 2024-07-12

A child in care did not receive medical treatment for a fracture until two days after their injury.

Resolution: Corrected: 2024-07-12

According to an incident report reviewed, a child disclosed of past sexual abuse. A report was not made to licensing until three days after a staff member and therapist became aware.

Resolution: Corrected: 2024-04-16

According to an incident report reviewed, a child disclosed of past sexual abuse. A report was not made to licensing until three days after a staff member and therapist became aware.

Resolution: Corrected: 2024-04-16

According to an incident report reviewed, a child disclosed of past sexual abuse. A report was not made to licensing until three days after a staff member and therapist became aware.

Resolution: Corrected: 2024-04-16

Medical consenter was not notified child in care received prescription medication until after the medication was given.

Resolution: Corrected: 2024-05-03

Medical consenter was not notified child in care received prescription medication until after the medication was given.

Resolution: Corrected: 2024-05-03

Medical consenter was not notified child in care received prescription medication until after the medication was given.

Resolution: Corrected: 2024-05-03

Two children in care were involved in a physical altercation. When staff separated the children, this left other residents unsupervised leading to another child in care being assaulted.

Resolution: Corrected: 2024-05-10

Two children in care were involved in a physical altercation. When staff separated the children, this left other residents unsupervised leading to another child in care being assaulted.

Resolution: Corrected: 2024-05-10

Two children in care were involved in a physical altercation. When staff separated the children, this left other residents unsupervised leading to another child in care being assaulted.

Resolution: Corrected: 2024-05-10

During a review conducted on February 8, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on February 1, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium weighted citation in a pattern/trend category on February 1, 2024. Specifically, the operation was cited for 748.2151(c)(6): Medication record - must include name & signature of person who administered each medication. The purpose of the signature is to be able to identify the person who administered a specific medication to a child if a concern arises later about that medication. Compliance of deficiency remains pending. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-02-09

During a review conducted on February 8, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on February 1, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium weighted citation in a pattern/trend category on February 1, 2024. Specifically, the operation was cited for 748.2151(c)(6): Medication record - must include name & signature of person who administered each medication. The purpose of the signature is to be able to identify the person who administered a specific medication to a child if a concern arises later about that medication. Compliance of deficiency remains pending. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-02-09

During a review conducted on February 8, 2024, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on February 1, 2024, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium weighted citation in a pattern/trend category on February 1, 2024. Specifically, the operation was cited for 748.2151(c)(6): Medication record - must include name & signature of person who administered each medication. The purpose of the signature is to be able to identify the person who administered a specific medication to a child if a concern arises later about that medication. Compliance of deficiency remains pending. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2024-02-09

The name/sigature of the staff who administered medications to a child in care was missing from the medication log.

Resolution: Corrected: 2024-02-07

The name/sigature of the staff who administered medications to a child in care was missing from the medication log.

Resolution: Corrected: 2024-02-07

The name/sigature of the staff who administered medications to a child in care was missing from the medication log.

Resolution: Corrected: 2024-02-07

Five children in care were left unattended on unit for ten minutes. During this time, one child pushes two children.

Resolution: Corrected: 2024-02-16

Multiple staff became aware of indications of neglectful supervision on the day it occurred. An incident report was not written at this time. The incident was called into the hotline 3 days after awareness.

Resolution: Corrected: 2024-02-16

Five children in care were left unattended on unit for ten minutes. During this time, one child pushes two children.

Resolution: Corrected: 2024-02-16

Multiple staff became aware of indications of neglectful supervision on the day it occurred. An incident report was not written at this time. The incident was called into the hotline 3 days after awareness.

Resolution: Corrected: 2024-02-16

Five children in care were left unattended on unit for ten minutes. During this time, one child pushes two children.

Resolution: Corrected: 2024-02-16

Multiple staff became aware of indications of neglectful supervision on the day it occurred. An incident report was not written at this time. The incident was called into the hotline 3 days after awareness.

Resolution: Corrected: 2024-02-16

Two children were in a physical altercation and the staff supervising was unable to intervene successfully to prevent harm to a child. Support staff was not available to respond immediately to the incident. The child involved had a history of physical altercations requiring safety precautions.

Resolution: Corrected: 2023-12-28

Two children were in a physical altercation and the staff supervising was unable to intervene successfully to prevent harm to a child. Support staff was not available to respond immediately to the incident. The child involved had a history of physical altercations requiring safety precautions.

Resolution: Corrected: 2023-12-28

Two children were in a physical altercation and the staff supervising was unable to intervene successfully to prevent harm to a child. Support staff was not available to respond immediately to the incident. The child involved had a history of physical altercations requiring safety precautions.

Resolution: Corrected: 2023-12-28

During a walkthrough of the cottage, hair and other debris was found on the bathroom sink counter and the floor.

Resolution: Corrected: 2023-11-22

During a walkthrough of the cottage, hair and other debris was found on the bathroom sink counter and the floor.

Resolution: Corrected: 2023-11-22

During a walkthrough of the cottage, hair and other debris was found on the bathroom sink counter and the floor.

Resolution: Corrected: 2023-11-22

Emergency evacuation signs did not notate a designated relocation area outside the operation.

Resolution: Corrected: 2023-11-10

Emergency evacuation signs did not notate a designated relocation area outside the operation.

Resolution: Corrected: 2023-11-10

Emergency evacuation signs did not notate a designated relocation area outside the operation.

Resolution: Corrected: 2023-11-10

Two direct care staff admitted to using profane language in the presence of children in care.

Resolution: Corrected: 2023-11-03

Licensing observed and photographed the surfacing material under the swings to be worn to down to the earth and the surrounding surfacing material to be compacted.

Resolution: Corrected: 2023-10-18

Licensing observed and photographed the surfacing material under the swings to be worn to down to the earth and the surrounding surfacing material to be compacted.

Resolution: Corrected: 2023-10-18

Licensing observed and photographed the surfacing material under the swings to be worn to down to the earth and the surrounding surfacing material to be compacted.

Resolution: Corrected: 2023-10-18

Two direct care staff admitted to using profane language in the presence of children in care.

Resolution: Corrected: 2023-11-03

Two direct care staff admitted to using profane language in the presence of children in care.

Resolution: Corrected: 2023-11-03

A child was escorted by police to a psychiatric hospital. Operation staff did not accompany the child. At the hospital, the child filled out the admission's paperwork and listed an unauthorized parent. The individual was able to gain knowledge of the incident and child?s whereabouts.

Resolution: Corrected: 2023-11-10

A child was escorted by police to a psychiatric hospital. Operation staff did not accompany the child. At the hospital, the child filled out the admission's paperwork and listed an unauthorized parent. The individual was able to gain knowledge of the incident and child?s whereabouts.

Resolution: Corrected: 2023-11-10

A child was escorted by police to a psychiatric hospital. Operation staff did not accompany the child. At the hospital, the child filled out the admission's paperwork and listed an unauthorized parent. The individual was able to gain knowledge of the incident and child?s whereabouts.

Resolution: Corrected: 2023-11-10

During the second restraint the child was observed being quiet and still for several minutes. Staff did not provide an opportunity for the child to be released.

Resolution: Corrected: 2023-10-25

During face to face interviews of the victim and collateral children, all five children in care stated they do not receive a sufficient quantity of food at meal times and are not allowed seconds even if they state they are hungry. All five also stated alternatives are not provided.

Resolution: Corrected: 2023-10-25

During the second restraint the child was observed being quiet and still for several minutes. Staff did not provide an opportunity for the child to be released.

Resolution: Corrected: 2023-10-25

During face to face interviews of the victim and collateral children, all five children in care stated they do not receive a sufficient quantity of food at meal times and are not allowed seconds even if they state they are hungry. All five also stated alternatives are not provided.

Resolution: Corrected: 2023-10-25

During the second restraint the child was observed being quiet and still for several minutes. Staff did not provide an opportunity for the child to be released.

Resolution: Corrected: 2023-10-25

During face to face interviews of the victim and collateral children, all five children in care stated they do not receive a sufficient quantity of food at meal times and are not allowed seconds even if they state they are hungry. All five also stated alternatives are not provided.

Resolution: Corrected: 2023-10-25

Video footage showed that staff allowed resident to walk past them while at the same time a dispute between residents in their room was happening and another staff was trying to handle the situation behind them. Staff in the hallway didn't attempt to prevent the resident from running into the other resident's dorm which led to punching the victim.

Resolution: Corrected: 2023-10-18

Video footage showed that staff allowed resident to walk past them while at the same time a dispute between residents in their room was happening and another staff was trying to handle the situation behind them. Staff in the hallway didn't attempt to prevent the resident from running into the other resident's dorm which led to punching the victim.

Resolution: Corrected: 2023-10-18

Video footage showed that staff allowed resident to walk past them while at the same time a dispute between residents in their room was happening and another staff was trying to handle the situation behind them. Staff in the hallway didn't attempt to prevent the resident from running into the other resident's dorm which led to punching the victim.

Resolution: Corrected: 2023-10-18

During a review conducted on August 8, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on August 3, 2023, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a high weighted citation in a pattern/trend category on August 3,2023. Specifically, the operation was cited for 748.685(a)(4) Caregiver responsibility - being able to intervene when necessary to ensure child's safety. The operation has until August 16, 2023, to meet compliance on. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-08-09

During a review conducted on August 8, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on August 3, 2023, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a high weighted citation in a pattern/trend category on August 3,2023. Specifically, the operation was cited for 748.685(a)(4) Caregiver responsibility - being able to intervene when necessary to ensure child's safety. The operation has until August 16, 2023, to meet compliance on. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-08-09

During a review conducted on August 8, 2023, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on August 3, 2023, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a high weighted citation in a pattern/trend category on August 3,2023. Specifically, the operation was cited for 748.685(a)(4) Caregiver responsibility - being able to intervene when necessary to ensure child's safety. The operation has until August 16, 2023, to meet compliance on. - Operation failed to satisfy the conditions of the plan - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring - Operation was unable to meet compliance with High weighted licensing citations Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2023-08-09

Direct care staff admitted a child in care was left behind in a residential area for 30 minutes. The child in care was not supposed to be alone for more than 15 minutes as per the child in care's service plan. Video footage also confirms this.

Resolution: Corrected: 2023-08-16

Direct care staff admitted a child in care was left behind in a residential area for 30 minutes. The child in care was not supposed to be alone for more than 15 minutes as per the child in care's service plan. Video footage also confirms this.

Resolution: Corrected: 2023-08-16

Direct care staff admitted a child in care was left behind in a residential area for 30 minutes. The child in care was not supposed to be alone for more than 15 minutes as per the child in care's service plan. Video footage also confirms this.

Resolution: Corrected: 2023-08-16

Medication administration was observed between 8:40 am and 8:51 am. The medication record was not updated from the scheduled medication administration time of 8 am. The time was not documented with the correct time of administration.

Resolution: Corrected: 2023-06-16

Medication administration was observed between 8:40 am and 8:51 am. The medication record was not updated from the scheduled medication administration time of 8 am. The time was not documented with the correct time of administration.

Resolution: Corrected: 2023-06-16

Medication administration was observed between 8:40 am and 8:51 am. The medication record was not updated from the scheduled medication administration time of 8 am. The time was not documented with the correct time of administration.

Resolution: Corrected: 2023-06-16

The incident was witnessed by two staff members and not reported by either. One staff interviewed states a supervisor and manager were also made aware of the incident on the day it occurred. An incident report was not completed at the time of the incident.

Resolution: Corrected: 2023-07-03

In observing video footage, the staff slaps the child's hand.

Resolution: Corrected: 2023-07-03

From witness interviews and video footage, a staff states, "it works on dogs to hold their nose closed." after plugging a child's nose.

Resolution: Corrected: 2023-07-03

A child's nose was plugged by staff which restricted the child's breathing.

Resolution: Corrected: 2023-07-03

A child's nose was plugged by staff which restricted the child's breathing.

Resolution: Corrected: 2023-07-03

In observing video footage, the staff slaps the child's hand.

Resolution: Corrected: 2023-07-03

A child was restrained by plugging of the nose by one staff while the nurse held the child in place in an attempt to have the child swallow their medication.

Resolution: Corrected: 2023-07-03

From witness interviews and video footage, a staff states, "it works on dogs to hold their nose closed." after plugging a child's nose.

Resolution: Corrected: 2023-07-03

The incident was witnessed by two staff members and not reported by either. One staff interviewed states a supervisor and manager were also made aware of the incident on the day it occurred. An incident report was not completed at the time of the incident.

Resolution: Corrected: 2023-07-03

A child's nose was plugged by staff which restricted the child's breathing.

Resolution: Corrected: 2023-07-03

A child was restrained by plugging of the nose by one staff while the nurse held the child in place in an attempt to have the child swallow their medication.

Resolution: Corrected: 2023-07-03

The incident was witnessed by two staff members and not reported by either. One staff interviewed states a supervisor and manager were also made aware of the incident on the day it occurred. An incident report was not completed at the time of the incident.

Resolution: Corrected: 2023-07-03

In observing video footage, the staff slaps the child's hand.

Resolution: Corrected: 2023-07-03

A child was restrained by plugging of the nose by one staff while the nurse held the child in place in an attempt to have the child swallow their medication.

Resolution: Corrected: 2023-07-03

From witness interviews and video footage, a staff states, "it works on dogs to hold their nose closed." after plugging a child's nose.

Resolution: Corrected: 2023-07-03

A child's service plan was not followed when the child self-harmed and a safety plan was not put in place. The child's service plan states due to the child's high risk of self-harming behaviors a safety plan should be implemented following this type of incident.

Resolution: Corrected: 2023-07-17

A child's service plan was not followed when the child self-harmed and a safety plan was not put in place. The child's service plan states due to the child's high risk of self-harming behaviors a safety plan should be implemented following this type of incident.

Resolution: Corrected: 2023-07-17

Caregivers and Medical staff were unaware of child's self-harming incident reported on 5/3/23 per interviews. Medical information was not shared from shift to shift according to interviews with nursing staff and caregivers. This information was also not documented in shift communication or progress notes observed.

Resolution: Corrected: 2023-07-17

Caregivers and Medical staff were unaware of child's self-harming incident reported on 5/3/23 per interviews. Medical information was not shared from shift to shift according to interviews with nursing staff and caregivers. This information was also not documented in shift communication or progress notes observed.

Resolution: Corrected: 2023-07-17

A child's service plan was not followed when the child self-harmed and a safety plan was not put in place. The child's service plan states due to the child's high risk of self-harming behaviors a safety plan should be implemented following this type of incident.

Resolution: Corrected: 2023-07-17

Caregivers and Medical staff were unaware of child's self-harming incident reported on 5/3/23 per interviews. Medical information was not shared from shift to shift according to interviews with nursing staff and caregivers. This information was also not documented in shift communication or progress notes observed.

Resolution: Corrected: 2023-07-17

A child in care was restrained and caseworker was not notified in a timely manner.

Resolution: Corrected: 2023-06-23

A child in care was restrained and caseworker was not notified in a timely manner.

Resolution: Corrected: 2023-06-23

A child in care was restrained and caseworker was not notified in a timely manner.

Resolution: Corrected: 2023-06-23

One staff member fell asleep while counted in ratio. Video footage shows the staff's alarm sounding and children waking her. The incident was confirmed in child interviews.

Resolution: Corrected: 2023-04-12

One staff member fell asleep while counted in ratio. Video footage shows the staff's alarm sounding and children waking her. The incident was confirmed in child interviews.

Resolution: Corrected: 2023-04-12

One staff member fell asleep while counted in ratio. Video footage shows the staff's alarm sounding and children waking her. The incident was confirmed in child interviews.

Resolution: Corrected: 2023-04-12

Two staff interviewed made statements that the staff to child ratio exceeded 1:5 during the incident. One staff said there were eight children. Another said there were at least six children. Interviews confirm two staff were present, however, one staff was in observations and not counted into ratio on the day of the incident. Management confirms the staff was not counted into ratio during their interview.

Resolution: Corrected: 2023-03-15

Two staff interviewed made statements that the staff to child ratio exceeded 1:5 during the incident. One staff said there were eight children. Another said there were at least six children. Interviews confirm two staff were present, however, one staff was in observations and not counted into ratio on the day of the incident. Management confirms the staff was not counted into ratio during their interview.

Resolution: Corrected: 2023-03-15

The child was not supervised in the staff only area allowing access to a craft knife which was later used for self-harming.

Resolution: Corrected: 2023-03-15

The child was not supervised in the staff only area allowing access to a craft knife which was later used for self-harming.

Resolution: Corrected: 2023-03-15

Two staff interviewed made statements that the staff to child ratio exceeded 1:5 during the incident. One staff said there were eight children. Another said there were at least six children. Interviews confirm two staff were present, however, one staff was in observations and not counted into ratio on the day of the incident. Management confirms the staff was not counted into ratio during their interview.

Resolution: Corrected: 2023-03-15

The child was not supervised in the staff only area allowing access to a craft knife which was later used for self-harming.

Resolution: Corrected: 2023-03-15

Medication was prepared four hours before time of administration.

Resolution: Corrected: 2023-01-24

Medication was prepared four hours before time of administration.

Resolution: Corrected: 2023-01-24

Medication was prepared four hours before time of administration.

Resolution: Corrected: 2023-01-24

In video footage reviewed, the caregiver exhibits a lack of urgency and fails to protect the child from harm. Body positioning was not positioned to protect the child from injury. The aggressive child was not restrained, and the targeted child was not removed.

Resolution: Corrected: 2023-02-03

In video footage reviewed, the caregiver exhibits a lack of urgency and fails to protect the child from harm. Body positioning was not positioned to protect the child from injury. The aggressive child was not restrained, and the targeted child was not removed.

Resolution: Corrected: 2023-02-03

After reviewing video footage, EBI curriculum, and staff statements, Emergency Behavioral Intervention training was not utilized on the aggressive child as required by the extent of possible physical injury. The child's hair was pulled twice, and she was kicked four times prior to the caregiver pulling out phone to call for assistance. The decision was made not to restrain the aggressive child without assistance despite the behaviors needing further management.

Resolution: Corrected: 2023-02-03

In video footage reviewed, the caregiver exhibits a lack of urgency and fails to protect the child from harm. Body positioning was not positioned to protect the child from injury. The aggressive child was not restrained, and the targeted child was not removed.

Resolution: Corrected: 2023-02-03

After reviewing video footage, EBI curriculum, and staff statements, Emergency Behavioral Intervention training was not utilized on the aggressive child as required by the extent of possible physical injury. The child's hair was pulled twice, and she was kicked four times prior to the caregiver pulling out phone to call for assistance. The decision was made not to restrain the aggressive child without assistance despite the behaviors needing further management.

Resolution: Corrected: 2023-02-03

After reviewing video footage, EBI curriculum, and staff statements, Emergency Behavioral Intervention training was not utilized on the aggressive child as required by the extent of possible physical injury. The child's hair was pulled twice, and she was kicked four times prior to the caregiver pulling out phone to call for assistance. The decision was made not to restrain the aggressive child without assistance despite the behaviors needing further management.

Resolution: Corrected: 2023-02-03

Shower was dirty and coming apart from wall.

Resolution: Corrected: 2022-12-30

Shower was dirty and coming apart from wall.

Resolution: Corrected: 2022-12-30

Shower was dirty and coming apart from wall.

Resolution: Corrected: 2022-12-30

Staff member used profanity and yelled at children in care.

Resolution: Corrected: 2023-01-13

Staff member used profanity and yelled at children in care.

Resolution: Corrected: 2023-01-13

Staff member used profanity and yelled at children in care.

Resolution: Corrected: 2023-01-13

During the walk through a wooden picnic table was seen blocking the side door.

Resolution: Corrected at inspection

During the walk through a wooden picnic table was seen blocking the side door.

Resolution: Corrected at inspection

During the walk through a wooden picnic table was seen blocking the side door.

Resolution: Corrected at inspection

During a review conducted on August 5, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on July 20, 2022, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium and medium-high weighted citation in a pattern/trend category on July 20, 2022. Specifically, the operation was cited for 748.2151(c)(6) and 748.2151(d) related to medication documentation. The operation met compliance on July 25, 2022. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-08-06

During a review conducted on August 5, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on July 20, 2022, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium and medium-high weighted citation in a pattern/trend category on July 20, 2022. Specifically, the operation was cited for 748.2151(c)(6) and 748.2151(d) related to medication documentation. The operation met compliance on July 25, 2022. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-08-06

During a review conducted on August 5, 2022, it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan(s); and (2) more than 12 months had elapsed since the effective date of the plan. As you know, the heightened monitoring plans for your operation included a specific ?planned end date? at the original 12-month mark by which your operation was expected to meet all heightened monitoring criteria necessary to move out of active heightened monitoring to a phase of ?post plan monitoring?. As a direct result of the administrator?s failure to ensure timely compliance with heightened monitoring plans, your operation was unable to successfully move to post-plan monitoring by the original ?planned end date? necessitating previous extension. Furthermore, due to your recent citations issued on July 20, 2022, your operation?s ?planned end date? must now be revised again, and the period of heightened monitoring must be extended again. Further details of the failure of your operation?s administrator to ensure compliance include the following: The operation received a medium and medium-high weighted citation in a pattern/trend category on July 20, 2022. Specifically, the operation was cited for 748.2151(c)(6) and 748.2151(d) related to medication documentation. The operation met compliance on July 25, 2022. - Operation failed to demonstrate 6 months of successive compliance with the standard and contract requirements that led to heightened monitoring; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations. Finding: 748.535(2) ? The licensed administrator must ensure the operation complies with current heightened monitoring plans.

Resolution: Corrected: 2022-08-06

During the review of three child medication records if was noticed that two staff who administered medication to a child in care had not written their name and/or signature in the section provided on the bottom of the medication log to identify their initials.

Resolution: Corrected: 2022-07-27

1 out of 3 child s medication record reviewed it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected: 2022-07-27

During the review of three child medication records if was noticed that two staff who administered medication to a child in care had not written their name and/or signature in the section provided on the bottom of the medication log to identify their initials.

Resolution: Corrected: 2022-07-27

1 out of 3 child s medication record reviewed it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected: 2022-07-27

1 out of 3 child s medication record reviewed it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected: 2022-07-27

During the review of three child medication records if was noticed that two staff who administered medication to a child in care had not written their name and/or signature in the section provided on the bottom of the medication log to identify their initials.

Resolution: Corrected: 2022-07-27

Two of the three child records reviewed did not have the child s TB test results located in the child s records. However the operation was able to request one child's TB test results and placed it in the child's file.

Resolution: Corrected at inspection

Two of the three child records reviewed did not have the child s TB test results located in the child s records. However the operation was able to request one child's TB test results and placed it in the child's file.

Resolution: Corrected at inspection

One of the three child records reviewed did not have an up to date TB test.

Resolution: Corrected: 2022-07-08

One of the three child records reviewed did not have an up to date TB test.

Resolution: Corrected: 2022-07-08

Two of the three child records reviewed did not have the child s TB test results located in the child s records. However the operation was able to request one child's TB test results and placed it in the child's file.

Resolution: Corrected at inspection

One of the three child records reviewed did not have an up to date TB test.

Resolution: Corrected: 2022-07-08

During the review of employee records, it was discovered that two direct care staff had not completed their required annual trainings.

Resolution: Corrected: 2022-05-25

During the review of employee records, it was discovered that two direct care staff had not completed their required annual trainings.

Resolution: Corrected: 2022-05-25

During the review of employee records, it was discovered that two direct care staff had not completed their required annual trainings.

Resolution: Corrected: 2022-05-25

During the review of a child's medication record it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected at inspection

During the review of a child's medication record it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected at inspection

During the review of a child's medication record it was discovered that a psychotropic medication count was documented incorrectly on the medication log.

Resolution: Corrected at inspection

One prescription medication was not documented as administered within the two hour timeframe.

Resolution: Corrected at inspection

One prescription medication was not documented as administered within the two hour timeframe.

Resolution: Corrected at inspection

One prescription medication was not documented as administered within the two hour timeframe.

Resolution: Corrected at inspection

A youth in care was left alone in the unit unsupervised.

Resolution: Corrected: 2022-01-11

A youth in care was left alone in the unit unsupervised.

Resolution: Corrected: 2022-01-11

A youth in care was left alone in the unit unsupervised.

Resolution: Corrected: 2022-01-11

A resident was on a safety plan and staff did not check on resident while showering. Resident got ahold of her hygiene and ingested her bottle of shampoo.

Resolution: Corrected: 2021-10-20

A resident was on a safety plan and staff did not check on resident while showering. Resident got ahold of her hygiene and ingested her bottle of shampoo.

Resolution: Corrected: 2021-10-20

A resident was on a safety plan and staff did not check on resident while showering. Resident got ahold of her hygiene and ingested her bottle of shampoo.

Resolution: Corrected: 2021-10-20

There was only one caregiver for 9 children for 30 minutes during the morning shift. The other staff memeber that was supposed to be on the unit had called in, and a replacement for the staff was not sent to the unit.

Resolution: Corrected: 2021-08-24

There was only one caregiver for 9 children for 30 minutes during the morning shift. The other staff memeber that was supposed to be on the unit had called in, and a replacement for the staff was not sent to the unit.

Resolution: Corrected: 2021-08-24

There was only one caregiver for 9 children for 30 minutes during the morning shift. The other staff memeber that was supposed to be on the unit had called in, and a replacement for the staff was not sent to the unit.

Resolution: Corrected: 2021-08-24

The operation staff discouraged children in care from writing grievances.

Resolution: Corrected: 2021-10-22

The operation staff discouraged children in care from writing grievances.

Resolution: Corrected: 2021-10-22

The operation staff discouraged children in care from writing grievances.

Resolution: Corrected: 2021-10-22

Last health inspection was completed on 4/30/2019. Therefore, operation did not complete the annual required health inspection.

Resolution: Corrected: 2021-07-29

Last health inspection was completed on 4/30/2019. Therefore, operation did not complete the annual required health inspection.

Resolution: Corrected: 2021-07-29

Last health inspection was completed on 4/30/2019. Therefore, operation did not complete the annual required health inspection.

Resolution: Corrected: 2021-07-29

The med log in the Olsen unit did not have staff's initials who administered meds for the PM shift on 7/6/21.

Resolution: Corrected: 2021-07-12

The med log in the Olsen unit did not have staff's initials who administered meds for the PM shift on 7/6/21.

Resolution: Corrected: 2021-07-12

The med log in the Olsen unit did not have staff's initials who administered meds for the PM shift on 7/6/21.

Resolution: Corrected: 2021-07-12

A light fixture wires were hanging down where residents could reach and pull down and a light bulb was broken.

Resolution: Corrected: 2021-09-07

Resident was standing on a table and staff moved the table causing resident to fall onto the ground, resulting in a fractured shoulder.

Resolution: Corrected: 2021-09-07

A light fixture wires were hanging down where residents could reach and pull down and a light bulb was broken.

Resolution: Corrected: 2021-09-07

Resident was standing on a table and staff moved the table causing resident to fall onto the ground, resulting in a fractured shoulder.

Resolution: Corrected: 2021-09-07

Resident was standing on a table and staff moved the table causing resident to fall onto the ground, resulting in a fractured shoulder.

Resolution: Corrected: 2021-09-07

A light fixture wires were hanging down where residents could reach and pull down and a light bulb was broken.

Resolution: Corrected: 2021-09-07

Operation staff left a resident at the cottage by herself when staff and residents went on outing. Resident was by herself for two hours.

Resolution: Corrected: 2021-07-30

Operation staff left a resident at the cottage by herself when staff and residents went on outing. Resident was by herself for two hours.

Resolution: Corrected: 2021-07-30

Operation staff left a resident at the cottage by herself when staff and residents went on outing. Resident was by herself for two hours.

Resolution: Corrected: 2021-07-30

Staff did not give resident appropriate space and resident became more dysregulated. Verbal de-escalation techniques were also not used.

Resolution: Corrected: 2021-07-17

Staff threw a water bottle and struck resident in the face.

Resolution: Corrected: 2021-07-17

Staff did not give resident appropriate space and resident became more dysregulated. Verbal de-escalation techniques were also not used.

Resolution: Corrected: 2021-07-17

Staff threw a water bottle and struck resident in the face.

Resolution: Corrected: 2021-07-17

Staff threw a water bottle and struck resident in the face.

Resolution: Corrected: 2021-07-17

Staff did not give resident appropriate space and resident became more dysregulated. Verbal de-escalation techniques were also not used.

Resolution: Corrected: 2021-07-17

Investigation documentation reveals operation staff had a note from a child in care expressing intention to commit suicide and shortly after the child in care was seen with a jacket around their neck and would not remove the jacket until staff threatened to cut the jacket off with scissors. The operation admits they did not count this as a suicide attempt and didn't report it.

Resolution: Corrected: 2021-06-18

Investigation documentation reveals operation staff had a note from a child in care expressing intention to commit suicide and shortly after the child in care was seen with a jacket around their neck and would not remove the jacket until staff threatened to cut the jacket off with scissors. The operation admits they did not count this as a suicide attempt and didn't report it.

Resolution: Corrected: 2021-06-18

Investigation documentation reveals operation staff had a note from a child in care expressing intention to commit suicide and shortly after the child in care was seen with a jacket around their neck and would not remove the jacket until staff threatened to cut the jacket off with scissors. The operation admits they did not count this as a suicide attempt and didn't report it.

Resolution: Corrected: 2021-06-18

A staff member shoved a resident in between restraints.

Resolution: Corrected: 2021-06-29

A staff member shoved a resident in between restraints.

Resolution: Corrected: 2021-06-29

A staff member shoved a resident in between restraints.

Resolution: Corrected: 2021-06-29

Staff supervise all children in care when calls are made, resulting in calls not remaining private.

Resolution: Corrected: 2021-07-01

Staff supervise all children in care when calls are made, resulting in calls not remaining private.

Resolution: Corrected: 2021-07-01

Staff supervise all children in care when calls are made, resulting in calls not remaining private.

Resolution: Corrected: 2021-07-01

Staff pushed resident with both hands with force back into her room, isolating her in her room with the door closed.

Resolution: Corrected: 2021-07-22

Staff pushed resident down on the ground, causing bruising.

Resolution: Corrected: 2021-07-22

Staff pushed resident with both hands with force back into her room, isolating her in her room with the door closed.

Resolution: Corrected: 2021-07-22

Staff pushed resident down on the ground, causing bruising.

Resolution: Corrected: 2021-07-22

Staff pushed resident with both hands with force back into her room, isolating her in her room with the door closed.

Resolution: Corrected: 2021-07-22

Staff pushed resident down on the ground, causing bruising.

Resolution: Corrected: 2021-07-22

Staff failed to properly maintain control of resident while attempting to de-escalate a situation. Staff struck child in the face with her fist.

Resolution: Corrected: 2021-06-01

Staff failed to properly maintain control of resident while attempting to de-escalate a situation. Staff struck child in the face with her fist.

Resolution: Corrected: 2021-06-01

Staff failed to properly maintain control of resident while attempting to de-escalate a situation. Staff struck child in the face with her fist.

Resolution: Corrected: 2021-06-01

Medication records, a professional medical collateral, medical care staff, direct care staff and child in care interviews together confirm a child in care missed one dose on one evening of a medication causing the child in care to feel upset and tired.

Resolution: Corrected: 2021-05-21

Medication records, a professional medical collateral, medical care staff, direct care staff and child in care interviews together confirm a child in care missed one dose on one evening of a medication causing the child in care to feel upset and tired.

Resolution: Corrected: 2021-05-21

Medication records, a professional medical collateral, medical care staff, direct care staff and child in care interviews together confirm a child in care missed one dose on one evening of a medication causing the child in care to feel upset and tired.

Resolution: Corrected: 2021-05-21