The Settlement Club Home GRO

During the inspection, I observed there to be food and trash left on food preparation areas. There were piles of debris left on floor where it was swept but not picked up. Stovetop was not clean as rice debris was left on it.

Three children touched one another inappropriately in the back seat of the facility van. Records note all three children have a history of poor boundaries that require close supervision.

During an investigation, residents indicated that they were squirted with a water gun that had a garlic powder in it. This was used as an intent to have residents come inside and take showers by a staff member.

During an investigation it was discovered a child in care was given another child in care's medication.

During an investigation that medication errors are not being documented within 24 hours but on a weekly basis and may not be being filled out by the person finding the error.

During an investigation, it was found multiple medications were not being given as prescribed.

The operation has allowed a staff member to smoke in an area that is not a safe distance from the children's living area.

During the inspection, the medication cart was not locked at the Moody Cottage staff office.

Through interviews it was determined that staff are cursing when talking to other staff and children in care can hear it.

Through interviews with staff and reviewing documentation, it was determined that signatures on medications logs were forged, and a therapy note contained inaccurate information.

A child in care self-harmed and was on a safety plan when the child in care self-harmed the next day using sharp items which were not allowed to be used unsupervised per the safety plan the day before.

A staff did not act prudently when storing a medication in a cup that a resident in care did not take. As a result, the medication could not be located by staff the following morning.

On 7/18/2024 six residents were not provided their morning medications.

During the investigation, it was made known that a staff member administered an over-the-counter medicine to a child in care who had an allergy to the medication.

During the investigation, it was made known that a staff member did not follow the operations policies when administering medications.

Three residents at the operation described seeing a staff member sleeping in the office on three separate occasions during the night hours.

During the inspection today, two fridges (white one and the small black one) at Casa Sara group home was observed without thermometers and one freezer was observed to be btw 15-20 degrees Farenheit. Additionally, on 5/10/24, the stainless steel fridge thermometer was observed to be over 40 degrees Farenheit and the other fridges didn't have thermometers either, these were at the same group home.

Through interviews and documentation, it was determined that children in care were not receiving therapy as required by their service plan therapeutic needs and goals.

It was reported a staff member cursed in the presence of a child in care. It was confirmed that a staff member cursed both at a child in care and in their presence.

During the course of this investigation, it was determined that a staff member used inappropriate language in the presence of children in care.

During an inspection of the RTC cottages it was observed that the couches in the living areas are torn in several places and have holes in them. Trash and other items are being stuffed into these holes.

During a walkthrough of the operation several food items were being stored in the cottage refrigerators with no lid or cover.

During an inspection of the cottage refrigerators, it was discovered that 2 residents had saved their leftovers on their plate and placed them in the refrigerator to continue to eat at a later time. Both plates were also uncovered.

During a walkthrough of the operation's main kitchen and the cottage kitchens, it was found that several food items were past their expiration date.

It was found that one staff with direct access to children in care has a provisional status pending an out-of-state background check as of 9/15/23 and the operation has not been following the conditions set by CBCU for this individual until the operation was informed by licensing on 12/15/23. This staff has been left alone with children in care as an awake night staff and has administered medications to children in care between these dates above.

During the course of the investigation, it was found that a staff administered a prescription medication for mood stabilization excessively to a child in care from Nov. 6 - Nov. 7, 2023 and did not follow the doctor's signed orders for this medication, the medication log, and/or the prescription instruction label. This medication was ordered to be administered by mouth twice daily. During the above-mentioned timeframe, staff administered this prescription medication twice in the morning (two 600 mg tablets) and once at night (one 600 mg tablet). Additionally, from 11/6/23 to 11/9/23, 11/14/23, and 11/16/23 this child's medications were administered by a staff person who was not supposed to administer meds to children in care due to a BCG condition. The operation was also cited for this same standard twice in 2022.

The medication cart was left unlocked as well as the staff office door, leaving the Schedule II medications accessible to all the residents and not double locked as required.

The medication cart was left unlocked and a child in care was able to gain access, ingest, and self-harm with another child's medication.

A child was able to get into the unlocked staff office, access and ingest medication from the unlocked medication cart and obtain a knife before staff was able to intervene.

In an investigation conducted by DFPS, one staff was confirmed to have medically neglected and neglectfully supervised a child in care.

It was reported and confirmed that a staff member used and held their cell phone while transporting children in care. It was also reported that the staff member had used their Air Pods to listen to a Podcast or YouTube Premium while driving children in care.

The parent was notified via email about the restraint occurring within 72 hours, however, the following required information was not included in the required timeframe: -the EBI administered -the length of the restraint -the child's condition following the release of the restraint

The EBI report for 8.22.23 did not document any attempts the staff made to explain to the child what behaviors were necessary for release from the restraint.

It was found that a staff left the children in the RTC alone on an outing at a McDonald's for approx. a couple to a few minutes.

The supervision requirements listed in the child's Service plan were confusing and contradictory not giving staff clear and understandable direction in meeting the child's needs.

The safety plan dated 7.10.23 states the following: Staff will complete 15-minute visual checks to ensure the child is committing to safety and remaining safe. This safety plan did not expire until 7.14.23. On 7.13.23 the child was issued a 2 hour unsupervised, off campus walking pass .

The daily progress note dated 3 days prior to the incident stated the child had high risk suicidal and runaway ideations. The child?s behavioral history in days prior to the incident should have been taken into account. The child was also on a safety plan requiring 15-minute visual checks for having suicidal and runaway ideations 3 days prior.

One of the ten Serious Incident Reports read were not reported to the Intake Line as required when police responded to the facility.

Staff administered a restraint in a non-emergency situation in order to obtain a THC and nicotine vape from a youth in care.

An overnight caregiver was noted to be sleeping during their shift.

One out of three staff files reviewed did not have current annual training in Normalcy, TIC, Psychotropic medication, and Reporting abuse and neglect.

In one of the two EBI Serious Incident Reports provided by the operation, the operation did not have a completed document with all required information. The report did not include the date and time the intervention was administered, did not provide any de-escalation techniques used, amount of time spent de-escalating with the youth, and did not include the date and time offered the discussion nor the child?s reaction to the opportunity for discussion. A completed document was subsequently completed and provided by the operation to RCCR over sixty days after the initiation of the EBI intervention.

In one of the two Serious Incident Reports provided by the operation, the notification of the Emergency Behavior Intervention to the Caseworker was dated as occurring six days after the incident occurred.

A child was able to gain access to ibuprofen that was being stored in a safety bag

A child in care, who had previously exhibited self harm behaviors, was left alone in a cottage with a Mental Health Officer (MHO). When leaving the cottage, a staff member failed to lock the top portion of the office door, where scissors were on the staff desk, and did not notify the MHO of the safety hazard. The child was able to gain access to the scissors and attempted to self harm once again.

Due to a window being faulty, a child was able to open it and enter into staff office. The child was then able to access a kitchen knife and self-harm.

It was identified 17 medication incident reports, used to document medication errors, were not documented within 24 hours.

It was Identified tha a child in care was prescribed medication on 05/27/2022 and this medication, as of 6/24/2022 has not been administered to the child.

It was identified that 2 medication rercords for 2 children in care lacked the signature of the person who administered the medication and the number of medication dispensed to each child.

It was identified that 2 medication rercords for 2 children in care lacked the signature of the person who administered the medication and the number of medication dispensed to each child.

The refrigerator located in CASA SARA had opened food items that were not stored in proper storage containers.

Medication was found in clear ziploc bags and not in the original container.

While conducting a walk through, the stove top and microwave were observed with stuck on food particles, the counter tops/food preparation area contained trash, the cabinet was hanging from its hinges, and the bottom of the freezer contained loose food that had fallen out of a package.

After a serious incident, staff assessed a child required heightened supervision through stabilization. Staff did not implement the needed supervision as the child was allowed to go outside unsupervised for over 15 minutes. During this time, the child was able to elope from the operation.

It was found during the investigation that periodically during an all for support call or a perimeter search, staff are left out of ratio for periods of time in both the RTC and GH cottages.

A child in care was able to find a piece of glass outside and swallow it. Other collateral children confirm that it is common to see hazards such as glass outside.

Two out of two cottages walked through were observed with unsealed or uncovered food items in the refrigerator or freezer. This was corrected at the inspection when staff conducting the walk through either covered the item or discarded it.

One out of two cottages observed, contained Schedule II medications that were not double locked as required. The office door was locked; however, the cart inside the office containing Schedule II medications was not locked and there were no staff observed in the area administering medication at that time. This was corrected at the inspection when operation staff locked the medication cart.

It was identified during this investigation that a male staff member entered a bathroom while a female child in care was showering.

A child in care was prescribed an inhaler for asthma that was to be used every 4 hours as needed. While participating in a higher risk water activity, the child began to have trouble breathing and wanted this inhaler. Caregivers had not brought the inhaler on the outing and therefore the child was not able to use their medication as prescribed. The child had a fainting episode and was taken to the emergency room.

A child in care was restrained over the maximum length of time. The restraint was said by staff to have lasted at least 30 minutes up to 45 minutes and was documented in the serious incident report to have lasted 40 minutes.

A direct care worker has been working at the operation with an inactive background check since June 2021.

A child and staff member tested positive for a communicable disease one tested positive on 12/31/2021 the other on 1/1/2022. The positive results were not reported to Licensing until 1/3/2022

The investigation concluded that a staff used condescending and sarcastic comments towards a child in care.

It was identified during the course of this investigation that expired medication was administered to a child in care. This medication was known by the operation to have been expired prior to the administration, continued to be accessible, and was administered to a child during a suspected medical event.

One employee who is counted in ratio, did not have first aid training.

Dish washing pods were observed in an unlocked cabinet in the kitchen at Moody cottage. Two out of three of the cottages that were walked through, did not show a return date for sharps that were checked out on a previous date in the month of August.

It was determined a child in care was denied a request to contact the Texas Abuse Hotline.

During the course of the investigation it was found a staff stopped working for the facility around Aug.4,2021, but was still showing as active on 8/15/21 and 8/26/21.

One of the toilets in the Nelson Cottage was observed with at least a half inch circle of mold and mildew around the inside rim of the toilet and a secondary circle of mildew was observed around the water line inside the toilet. The sink in that same bathroom was observed to have some type of brown and red dried up splatters. On June 4 the administrator incdicated that the bathrooms in Nelson Home were in need of deep cleaning.

Five individuals interviewed acknowledged witnessing staff, who acknowledged being responsible for checking on the children, sleeping during their shift.

During the course of the investigation it was found that the window alarm went off and was heard, but no one checked to ensure that it was not from the staff entering and leaving the building. Furthermore it was determined supervision was done primarily through the cameras knowing the victims were upset and had a history of running away.

During the course of the investigation it was determined there was an issue with mold/mildew in the children's shower.

It was found that on 5/6/21, the child/victim was supposed to be using the front bathroom in the cottage to shower according to the safety plan in place (as of 4/29/21) and according to collateral reports, however the child switched bathrooms with another resident without staffs' knowledge or awareness. The child/victim went to shower in own bathroom instead and ended up falling and hitting their forehead on the bathroom counter and was taken to the hospital. According to the safety plan and collateral reports, the child was supposed to also be getting checked on every 5 minutes while showering due to safety concerns, however staff were not aware of the two children switching bathrooms until after child/victim informed one of the cottage staff of falling and hitting their head. It was reported, the staff that the child informed had left the cottage to run errands on campus and had returned after approx. 20 min. while the other staff had remained at the cottage.

The kitchens in Moody, Scarborough, and Nelson have both old and new food splatter on the cabinets and appliances. Concerns about the cleanliness and state of the kitchen have been addressed in multiple inspections and the condition appears to be the same if not worsened.

A caregiver did not demonstrate self-control when they became angry and yelled in front of the children and slammed doors.

During interviews with staff and residents, it was determined that one staff member is imposing consequences on children in care that is excessive for the behavior that the children demonstrated. This staff is also not consistent with giving consequences.

A razor/shaving tool with a sharp blade was observed to be in the bedroom of children in care. The children had not checked out the razor according to the check in/out list.

The closet where cleaning chemicals are stored was unlocked and open, allowing a child the opportunity to take one and ingest it.

A child in care who was placed in this cottage to stabilize for unsafe behaviors was able to access a metal bracket for a shelving unit in an unlocked closet, a staple from the wall and a butter knife from the kitchen. The child made some superficial cuts to their arm and also ingested cleaning chemicals. During this time, a staff member who was responsible was reportedly outside of the cottage and unable see the child. They also reported that while the therapist was on the unit, was not told to supervise the child.