Pegasus Schools, Inc.

It was observed that an expired medication was left in the medication locker and was still being used.

During the physical site inspection, several concerns were observed throughout all of the dorm's bathrooms and shower areas. Showers were observed to have mold and other bacteria growing, dripping shower heads, shower heads that squirt water out of the shower area, leaking soap dispensers, bacteria growing on water fountains, and rusty screws on both toilet seats and faucets.

It was observed that an expired medication was left in the medication locker and was still being used.

During the physical site inspection, several concerns were observed throughout all of the dorm's bathrooms and shower areas. Showers were observed to have mold and other bacteria growing, dripping shower heads, shower heads that squirt water out of the shower area, leaking soap dispensers, bacteria growing on water fountains, and rusty screws on both toilet seats and faucets.

Review of the Serious Incident Report, Medical Documentation, and CLASS showed the incident occurred on 9/24/24 and was not reported until 9/26/24.

Evidence supports that multiple children in care were able to engage in sexual activity while the same caregiver was supervising those children on multiple occasions.

In their interviews staff stated that they have either seen or have nodded off while on shift.

Evidence was provided showing that staff member provided their personal number and social media to a child in care. In addition, communication with a discharged child was deemed inappropriate.

In an interview, a staff member admitted that they had on occasion fallen asleep. In an additional interview, a child in care stated that they witnessed the staff member sleeping during school hours.

During the course of the investigation, it was determined that a caregiver allowed children to be unsupervised in the community for short periods of time.

It was determined that a staff member was heard yelling at a child in care to comply with their request prior to conducting a restraint.

Multiple children and staff reported that a staff member placed a child on an escort hold because they were cursing, threatening peers, and threatening to run.

During a physical inspection is was observed that the door to medication room and the medication cabinet were left unlocked.

During the investigation, it was found that two children in care went behind a golf cart outside during recreation time for a period of approx. 5 minutes and staff were unaware of their whereabouts during this time. It was reported the two children were supposed to remain within eyesight of staff. Additionally, the staff that was reportedly responsible for watching one or both of the children involved is currently on Provisional status with conditions.

It was found that a staff who was reportedly supervising one or both children in care involved during this incident is currently on Provisional status with conditions.

During the review of medications, it was found that 4 children had med counts that didn't match the count that the med log noted.

Through interviews it was determined that, while in the PPL room, staff and residents were out of ratio for a period of time.

Through information gathered, it was determined that staff members subjected children in care to inappropriate and obscene language.

It was determined and confirmed that children in care were not provided raincoats to protect themselves from the rain, staff members attempted to persuade children in care from submitting grievances, staff displayed and fidgeted with a knife while caring for children, staff threatened EBI if the children touch their knife, staff threatened children after being released, staff used their personal cell phones to send text messages and make personal phone calls, while leaving the dorm out of ratio, and released confidential information to the children in their care.

It was reported and confirmed that staff instructed and directed children in care to walk a lap by the staff parking lot while it was raining because they were chatty and particularly talkative, and they did not comply with the staff?s warning. It was also confirmed that although not while raining, this form of punishment has occurred on multiple occasions and was described as very ordinary.

Through video surveillance and interviews it was determined that residents were not adequately supervised and were able to have inappropriate contact.

While reviewing the service plan it was observed that a significant portion of the requirements are missing.

During the course of the investigation, it was determined that a caregiver failed to treat all residents fairly in terms of consequences for their actions which may have negatively impacts a child?s positive success in the program.

During the investigation, it was determined that a caregiver have been observed yelling at the children and shaming them for behaving inappropriately.

During the course of the investigation, it was determined that caregivers are subjecting children to profane language on a regular basis.

During the course of the investigation it was determined two children in care were able to speak to each other from their bunks in an inappropriate manner during sleeping hours for six consecutive days.

It was found one staff person was falling asleep for short periods of time while at work.

When completing the walktrhough, a staff was observed yelling and tellling a kid to shut up.

During interviews and review of video footage, it was determined that a child in care was restrained due to not wanting to get up from sitting on the floor.

Multiple food items were stored in open bags.

It was determined that a staff member used threats of getting physical if residents didn't calm down.

During the course of this investigation, it was determined that staff did not adequately supervise a child at the operation during recreation time and the child sustained a serious injury.

During the investigation, it was determined that staff members used profane language in front of or directed at children in care.

There is sufficient evidence to show a staff member was sleeping while being counted in ratio.

It was determined that a caretaker gave multiple tablets of over-the-counter medication at once, on multiple occasions, to numerous children in care without the approval of a healthcare provider and/or management.

During the course of this investigation, it was determined that a caretaker gave over-the-counter medication to children in care on multiple occasions and did not document it in the children?s medication record.

Medications were not being properly documented in two dorms. In one dorm the medication had already been documented for night medicine that had not been administered and in another dorm the staff put their initials but did not fill out the rest of the documentation.

During the course of the investigation, four (4) individuals reported one particular staff uses language towards the children in care that is ridiculing and/or belittling in nature.

There is sufficient evidence to show that night staff are not providing an appropriate level of supervision and are being distracted by paperwork.

After conducting the investigation, two children in care reported that they touched each other inappropriately on top of clothing and the staff supervising either did not see and/or was not paying attention and this may have been due to the staff either being on their phone and/or sleeping in the classroom when supposed to be supervising. It was also reported that this staff and multiple other staff close their eyes/nod off/sleep in the classroom for short periods of time when supposed to be supervising and at times wear a cap and/or sunglasses which may be preventing them from supervising properly.

During the course of this investigation, it was determined that a caretaker did not follow protocol in checking children in care as they entered the shower and/or latrines. It was also determined that a caretaker was not made aware of an active Safety Plan for a child under their care.

A caregiver did not demonstrate self-control when they cursed at a child to get them out of bed and then forcefully pulled the child out of their bed.

Multiple training records showed staff were getting sometimes more than 20 hours of training in a day.

During the course of the investigation, it was determined that a staff member subjected a child to insulting, offensive language.

There is sufficient evidence to show a staff member cursed at and threatened a child and allowed other children in care to curse at the child.

Licensing requested EBI training for the two direct care staff involved in this incident on 6/23/21 and one of the two staff EBI training complete records/current records was not provided to licensing by the operation until 8/16/21. On 6/24/21, the operation provided EBI records for this staff from 2018 and 2019. On 8/11/21, the operation provided additional EBI training for this staff from 2019 and 2020, then on 8/16/21, the operation provided current EBI training for this staff from 2021.

There is a preponderance of evidence that a staff member allowed inappropriate contact between themself and children in care.

After reviewing the child's service plan, it was found that several required sections of the service plan were missing.

Staff instigated a child to react violently when they physically attempted to remove their shoes resulting in the child being restrained.

A child in care was left unsupervised for 21 min allowing the child time to attempt suicide.