Abuses at a Pueblo center for people with severe intellectual disabilities included a resident performing a sexual act in exchange for a soda and another burned with a blow dryer in an attempt to raise her body temperature, according to a federal report obtained by The Denver Post.

A group of men, some who are nonverbal, had words scratched into their skin, including “die,” “kill,” and “I’m back,” federal investigators found. When questioned, three staffers said they believed the markings were the result of “paranormal activity.” Staffers had posted photos of the etchings on social media, the report said.

The incidences of abuse at the Pueblo Regional Center — one of three centers in Colorado that are home to adults with developmental, physical and intellectual disabilities — occurred before November 2015. Yet federal investigators who visited the home in April found safety protocols still lacking. They notified Colorado Medicaid officials in an August letter that they were enacting a moratorium on new residents at the center and that Colorado must repay millions of dollars in Medicaid funding.

“These are some of our most vulnerable people in Colorado,” said Stephanie Garcia, executive director of The Arc in Pueblo, a nonprofit advocacy group for people with developmental disabilities. “To read some of the things going on, it’s shocking.

“It’s much worse than we thought. It seems like every system of oversight failed. We should have checks and balances in place,” she said.

This week, the Colorado Department of Health Care Policy and Financing, which manages the federal and state Medicaid dollars that support the Pueblo center, asked federal officials to reconsider the cash penalties and said the state already has fixed most of the issues identified in the required corrective action plan. HCPF is the fiscal agent for the regional centers and is in charge of ensuring the state human services department properly manages the daily operations at the centers.

In the last 18 months, state officials conducted “intense retraining” of staff, have visited the Pueblo center 13 times and began scrutinizing its reporting of critical incidents almost daily, the state’s health care policy and financing executive director, Susan Birch, said Tuesday.

Federal officials blasted state oversight, saying state Medicaid officials did not properly investigate despite “numerous severe incidents reported,” and that the Pueblo center “has a history of not properly reporting or responding to incidents.” The state did not “identify the trends, problematic practices or provide follow-up for the incidents,” the report said.

Birch said the staff in her department “is only as good as the information that they have to work with,” adding that critical information was not reported by the Pueblo center to the state or the local community-centered board.

“We absolutely own that there was a systems problem,” she said. “Had our staff known, I fully expect they would have acted appropriately and much more quickly.”

In April 2015, state human services officials conducted “body audits” on 62 residents of the Pueblo center after abuse allegations. The audits were done without consent or knowledge of the guardians, prompting a backlash from legislators, who wrote a letter to Gov. John Hickenlooper calling for a change in leadership at the state’s human services department. The state health department determined the body checks were a violation of residents’ rights.

Pueblo County sheriff’s officials also investigated at least “19 complaints of abuse, maltreatment and unlawful sexual contact,” according to the federal report. In some instances, the sheriff’s office substantiated abuse that the center did not, including the allegation of sexual abuse. In at least one case, criminal charges were filed after allegations of physical assault. The director of the center resigned in May 2015, saying the reports of abuse were unfounded. Eight employees resigned or were terminated, and another eight were disciplined.

After those strip searches of residents, the federal Centers for Medicare and Medicaid Services began a review of the alleged abuse. The federal investigation included a four-day visit to Pueblo five months ago. Among the issues discovered during that April visit: improper use of physical restraints that “could have resulted in serious injury,” and bruising and rug burns on a resident.

Federal officials determined that numerous incidents “that gave rise to the body audits” were substantiated and “clearly posed a risk to the health and safety” of residents. Also, their on-site review “revealed that a number of serious incidents have continued to occur.”

The federal report provides new details on the abuse, including that three residents had died, two from bowel obstructions and one who collapsed and was not given life-saving care because a staffer mistakenly thought there was a “do-not-resuscitate” order. A staff resident locked a resident outside in the cold for two hours as punishment, and in another case, a staffer assaulted multiple “vulnerable” individuals by hitting their legs and arms, covering one person’s head with a blanket and threatening to “slash the throat” of another. Criminal charges were filed against that staff member. In another incident, an intoxicated staff member drove a resident to a doctor’s appointment, the federal report says.

State human services director Reggie Bicha said he was dismayed that the report came out a year and a half after the abuse incidents and did not make clear the human services department “uncovered it and exposed it and held folks accountable.” A deputy at the department learned of the scratched words on residents’ bodies in February 2015, three months after that incident occurred. An internal investigation that lasted six weeks found that Pueblo center leaders had not fully reported that incident and others to law enforcement or the state, Bicha said.

“We have been making dramatic changes in policy and oversight and our work continues,” he said, adding that he plans to increase staff at the Pueblo center by 20 people, from 195 to 215. Bicha also wants to increase salaries and improve recruitment to improve staff turnover rates. Since the incidents, five out of six leadership positions in Pueblo have changed.

The majority of the staff at the center is compassionate and committed, but a year-long period of bad leadership led to a culture of fear and retaliation at the center, he said.

Sen. Kent Lambert, a Colorado Springs Republican and a member of the legislature’s joint budget committee, said he was particularly concerned about the communication issues, beginning at the Pueblo center and reaching the state department of health care policy and financing.

“There are some very, very serious communication concerns all the way down the line on that issue,” he said. “We see a lot of finger-pointing here, and that’s not necessarily helpful.”

The federal report adds that 90 percent of the Pueblo center’s residents are prescribed psychotropic medications, but the center has failed to ensure residents and their guardians received sufficient information necessary for informed consent to take the medications. In addition, the use of those medications was not properly monitored, the report found.

State Rep. Dave Young, a Greeley Democrat and also a member of the joint budget committee, has a sister who lives at the center in Pueblo. He said he’s concerned because the federal report shows the state still hasn’t fixed staffing issues that legislators raised concerns about a year ago.

For his sister, the lack of oversight of her psychotropic medications could prove fatal since she recently had a liver transplant, Young said. He added that expecting those living at the center to find adequate care in community residential settings won’t work for everyone. His sister struggled with 20 residential placements in one year before finally getting into the Pueblo center.

“When we have dramatic changes in services to such a vulnerable population, gaps in service can have massive impact on their safety,” Young said. “They have the potential to become life or death situations for these people.”

Officials with the Centers for Medicare and Medicaid Services said the state must return Medicaid funds paid to house the disabled at the center from November 2014 through November 2015.

The extent of the financial penalty is still under negotiation. A previous audit found that the center spent about $7.8 million in Medicaid funds in state fiscal year 2013. About 60 people with intellectual and developmental disabilities live at the center.