The Burke Foundation-Pathfinders RTC

It was observed a staff member restrained a child in care when they did not listen to staff directives to walk away from a sitting child.

It was observed staff did not meet EBI training requirements within 6 months from the date they last received training.

It was observed a staff member used excessive force to initiate a restraint by grabbing a child in care's arm from behind and swinging them into a door.

It was observed multiple children watched a child in care be restrained. One child walked by the restraint and taunted the child in the restraint.

During a review conducted on 09/22/25 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 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 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. Further details of the administrator?s failure 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; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations.

Review of the SIR showed that the runaway incident occurred at 12:59 AM on 8/29/2025 and the caseworkers were not informed until 8:00 AM on 8/30/2025 which is outside of the 6 hour requirment.

A child concealed and saved four pills over the course of two weeks during medication administration. The child intentionally ingested all four at a later time and required medical attention.

A child in care reported seeing a caregiver sleeping while on duty. The child called out to the caregiver twice for permission to use the restroom with no response. Caregiver reported to doze off on multiple occasions.

Three children in care reported seeing a caregiver sleeping during the night shift with no other caregivers present. One caregiver reported waking this caregiver up upon starting a morning shift.

During a review conducted on 03/20/2025 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 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 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. 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 03/14/2025. Specifically, the operation was cited for 748.507(1). It was found that a former direct care staff allowed children in care to participate in tug-o-war/wrestling with each other and this staff person was involved in the wrestling as well. It was reported that this staff also allowed the children to take off their shirts while working out in the weight room due to a lack in adequate A/C being available. - 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.

After a resident asked for additional food in the cafeteria, an employee tossed a food tray in the direction a resident striking their rib and landing on the floor.

An employee was seen using a vaporizer inside the residents living area at the front desk.

Two employees were observed inappropriately touching each other at the front desk of the operation and entering a supply closet together for approx. 5 mins.

A caregiver was observed via camera, outside the dorm in a car, leaving residents unsupervised for approximately 10 min.

During a review conducted on 09/19/2024 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 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 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. 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 08/30/24. Specifically, the operation was cited for 748.2605(a)(5). While reviewing video footage a staff was observed twisting a child's arm behind their back during an improper restraint. - 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.

During the investigation, a caregiver admitted to falling asleep on multiple occasions on an overnight shift.

This standard was found deficient as part of a DFPS Investigation.

While reviewing video footage a staff was observed twisting a child's arm behind their back during an improper restraint.

Through interviews and video footage, it was determined that staff did not attempt to de-escalate a child before using emergency behavior intervention.

It was observed through video footage, that a staff was pushing and pulling on a child in care when escorting the child.

Through interviews and video footage, it was determined that a staff twisted a child's arm behind their back during a hold.

Through interviews and video footage, it was determined that a staff performed an inappropriate and unwarranted intervention on a child in care.

In the ISP under the 'services to address high risk behavior' it states staff are to use the least restrictive method unless the resident is walking past the soccer field. Staff did not adhere to these instructions when restraining the child inside the operation.

A child in care was restrained at the door of the operation and escorted to a couch where the restrain resumed to prevent the resident from going outside.

The preliminary service plan did not indicate the child has autism spectrum disorder.

The operation did not document a restraint report for the incident.

A child in care was restrained for over 10 minutes.

A child in care was held in a restraint for an excessive amount of time.

During a review conducted on 03/18/2024 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 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 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. 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 01/08/24. Specifically, the operation was cited for 748.685(a)(4). It was reported that a staff is on their phone or computer a lot of the time looking at social media (such as Instagram, Tik Tok, and/or Facebook) or YouTube while working and while supervising children in care. - 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.

Two caregivers failed to provide a child a high level of supervision which was required by the instructions on their service plans.

An employee at the operation tested positive for THC and did not provide the required documention to substantiate the positive result.

The operation had a failed fire inspection in July 2023 and a follow up inspection in November 2023 and were recited for two of the same violations.

It was reported that a staff is on their phone or computer a lot of the time looking at social media (such as Instagram, Tik Tok, and/or Facebook) or YouTube while working and while supervising children in care.

It was reported that for the incident a staff argued back and forth with a child in care, yelled and said shut up to the same child and other children in care and did not de-escalate the situation properly. Additionally, this same staff was reported to have made threats of consequences to children in care for asking a question and making inappropriate comments about children in care sitting next to each other.

The operation staff conducts a monthly interview with the children in care and did not report when a child alleged that a staff inappropriately restrained him.

During a review conducted on 09/15/2023 it was determined that: (1) your operation?s administrator failed to ensure compliance with the current HM Plan; and (2) 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 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. 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 09/01/2023. Specifically, the operation was cited for 748.1101(b)(4)(A) It was found that a staff person treated a child in care unfairly by giving unnecessary discipline and/or excessive consequences to this child. - 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; 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.

A staff member did not use prudent judgment when he told a child, "You cannot join the military if you pee the bed."

A staff member admitted to vaping in the buildings on campus. The staff member explained they step into a room where the children are not currently present then will vape. Staff stated this is allowed as long as it is not in sight of the children. The tobacco policy does not dictate that staff may not vape in children's living areas/inside any building on premises with children, only that is it is not to be done in front of children.

After reviewing video footage and from interviews, it is determined that a child was placed in a restraint for a non-emergency situation.

When reviewing video footage, one staff is seen pushing down on the back of Noah and pushing him towards the ground.

A restraint implemented on 5/16 had not been documented within the required 24 hour period.

A restraint given on 5/16 did not have a review by a supervisor documented within the required 72 hours of the incident occurring.

It was found that one staff used a vape pen and vaped on multiple occasions in front of and/or near children in care. The operation was cited for this standard in July 2022 as well.

Based on the EBI video and documentation, the child was led away from the wall by the arm then subsequently, restrained causing injury to the child's foot, when there was no indication the child was going to run away, self-harm or harm others at that time.

In an investigation conducted by DFPS, it was determined that physical abuse occurred when a child injured his foot during a restraint.

Three staff were observed on video holding a child on the ground in a restraint for at least four minutes after he was no longer a danger to himself or others and had expressed that his foot was injured.

During a restraint, staff was seen lifting a child off of the ground, which is not a permitted type of EBI and resulted in the child being injured.

Staff was observed via the EBI video, using excessive force when he lifted the child off of the ground during a restraint, causing the child's feet to drag; consequently, causing both child and staff to fall to the ground and injuring the child's foot.

The caregiver was observed grabbing the child's shirt and belt loop, wrestling with him on the ground, and forcing him to sit in a chair, which are not approved methods of EBI.

Two caregivers were observed pushing down on the child's back, while both caregivers each held one arm and were pulling back and up on the child's arms until both arms were extended and behind his back.

In an investigation conducted by DFPS, two staff were found reason to believe for physical abuse of a child.

A child was observed outside doing jumping jacks when he was restrained by staff in a non-emergency situation.

A staff was observed on video restraining a child in a non-emergency situation.

Staff was observed holding a child's arms behind his back during a restraint.

I observed a total of 6 fire extinguishers in the boys' dorms. All 6 fire extinguishers were inspected in February 2022.

Based on information obtained, it was determined that a child was denied basic rights as a discipline when the child did not comply to staff directives. (The child was not allowed to go into the cafeteria and eat until he quit making noises)

During a review conducted on 03/13/2023 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plan; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plan for this operation included a specific ?planned end date? at the 12-month mark by which the 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 the heightened monitoring plan, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure to ensure compliance include the following: - 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; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

A listening device was secretly placed in a room where RC staff were conducting interviews. This was noticed by RC staff and the device was turned off. The person who planted this device admitted to doing this at the request of the administrator.

A staff was observed administering a restraint to a child in a non-emergency situation.

During a review conducted on 09/16/2022 it was determined that: (1) the Administrator failed to ensure compliance with the current HM Plans; and (2) 12 months had elapsed since the effective date of the plan. The heightened monitoring plans for this operation included a specific ?planned end date? at the 12-month mark by which the 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, this operation is now unable to successfully move to post-plan monitoring. Furthermore, the operation?s ?planned end date? must now be revised, and the period of heightened monitoring must be extended. Further details of the administrator?s failure 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; and - Operation was unable to meet compliance with Medium-High or High weighted licensing citations, including having an open investigation.

Two out of two children's files reviewed did not contain results of a TB exam and both have been placed at the facility for over 40 days.

Based on information gathered through the course of the investigation it has been determined that children are not always being granted privacy when trying to make phone calls with their CPS worker or CASAs.

Based on interviews and documentation, it was determined that a child was restrained after throwing a canteen into open space.

It was determined during the course of this investigation that a staff member has used a vape in the children?s living quarters.

During interviews with children and staff, as well as a review of emergency behavior intervention (EBI) documentation, it was determined staff have implemented EBI in situations which do not meet the definition of an emergency situation. The information gathered indicates restraints have been used when a child walks out of supervision, or as a preventive measure when a child has been perceived to potentially escalate their peers? behavior.

Six children interviewed during the course of this investigation, along with two staff, confirmed that staff have yelled at children in care.

During interviews with both children and staff, it was determined children occasionally have to ?hold the line? for over 15 minutes. The manner in which ?holding the line? was characterized suggests this is a disciplinary measure, to include the following characteristics: a child having to stand straight up, facing forward, with their hands behind their backs and toes on the line, all while remaining silent.

Seven children interviewed, along with three staff, explained staff have used profane language around children in care.

6 children interviewed explained staff had used profane language around them, whether the staff was being negative or using the language in a "joking" manner.

When observing video footage, it was observed that a child in care remained in a restraint after no longer being a threat to himself or those around him.

Out of multiple interviews conducted with children and staff, it was confirmed that a caregiver openly calls the children in care "stupid" and humiliates children who have wet the bed by calling them "pee pee boy" or "bedwetter" in font of their peers by using shame as a discipline technique.

There is sufficient evidence to show that a staff member is retaliating against a child in care they feel contacted Licensing about them. Both staff and children in care interviewed stated the staff member is retaliating against the child by calling the child ?allegations boy?, ?licensing boy? and making other comments openly to other children that penalize them for speaking with Licensing.

During the course of the investigation, according to video footage reviewed, on 11/17/21, a child in care initiated in what was characterized as "horseplay" and/or play fighting with one staff, in which the staff engaged in with the child resulting in a physical incident with the child, which included contact to the child?s person. This behavior was inappropriate as the child's plan of service, completed on 08/01/21, notes a history of trauma, as well as a history of physical aggression and emotional dysregulation. It was also reported that on the same day the aforementioned incident occurred, this staff engaged in "horseplay" with the resident by removing the child's bedsheet from their mattress as a joke and/or threw the child?s mattress, bedding, and belongings about the child?s room. It was reported that this staff "flipped" this child's room not as a consequence, but in a joking manner. The operation reported this staff's last day is 11/19/21.

Through interviews it was determined that staff implemented an emergency behavior intervention when it was not an emergency situation. Staff were putting children in restraints for throwing objects such as rocks or sticks when others were not in imminent danger of being harmed and staff would put children in short personal restraints for not taking their hands out of their pockets.

Based on interviews conducted and information obtained, it was determined that staff threatened to administer a restraint to a child in care. Subsequently, the child was placed in a restraint for failing to comply with directives.

During the course of this investigation, it was determined that staff administered a restraint to a child in care in a nonemergency situation when the child's behavior was refusing to lay down and refusing to go to sleep.