Oakwood Facility

Deficiency cited, complaint survey : V 366} 27G .0603 Incident Response Requirements

Based on record review and interviews, the facility failed to implement written policies governing their response to level II incidents. The findings are: Review on 01/06/25 of Former Client (FC) #1's record revealed: - 16 year old female. - Admission date of 09/04/25. - Diagnoses of Major Depressive Disorder-Severe with Psychotic Symptoms, Oppositional Defiant Disorder, Eating Disorder and Attention Deficit Hyperactivity Disorder. - No level Il incident report for FC #1's Involuntary Commitment (IVC) on 12/08/25. Review on 01/06/25 of a physician order for FC #1 dated 12/08/25 revealed: - "May IVC to [local hospital] ER (emergency room) for eval (evaluation) and tx (treatment) r/t (related to) self endangerment." Review on 01/06/25 of "Progress Notes" for FC #1 revealed: - 12/08/25 at 10:37am - Psychiatrist notified of therapeutic wrap and need for IVC and IVC order given. - 12/08/25 at 11:01am - "Guardian/mother notified of therapeutic wrap and consumer (FC #1) IVC. Guardian had concerns of if she was going to return to Oakwood or what the plan would be after IVC. Guardian wanted to speak with therapist. transferred call to therapist." - 12/08/25 at 1:36pm - "Consumer Affairs Coordinator notified guardian of IVC. Sheriff picked her up at 1:36pm." - 12/08/25 at 1:36pm - "Consumer was picked up by [sheriff office] and transported [local hospital] for IVC. Mom was made aware of plan and would like to be called with updates as available. Consumer was calm and went willingly ...

Deficiency cited, complaint survey : V 367| 27G .0604 Incident Reporting Requirements

Based on record review and interview, the facility failed to notify the Local Management Entity/Managed Care Organization (LME/MCO) of level Il incidents as required. The findings are: Review on 01/07/25 of the North Carolina Incident Response Improvement System (IRIS) revealed no Level II incident report had been submitted for Former Client (FC) #1's Involuntary Commitment on 12/08/25 Review on 01/06/25 of FC #1's record revealed: - 16 year old female. - Admission date of 09/04/25. - Diagnoses of Major Depressive Disorder-Severe with Psychotic Symptoms, Oppositional Defiant Disorder, Eating Disorder and Attention Deficit Hyperactivity Disorder. - No level II incident report had been submitted to the LME/MCO for FC #1's IVC on 12/08/25. Review on 01/06/25 of a physician order for FC #1 dated 12/08/25 revealed: - "May IVC to [local hospital] ER (emergency room) for eval (evaluation) and tx (treatment) r/t (related to) self endangerment." Review on 01/06/25 of "Progress Notes" for FC #1 revealed: - 12/08/25 at 10:37am - Psychiatrist notified of therapeutic wrap and need for IVC and IVC order given. - 12/08/25 at 11:01am - "Guardian/mother notified of therapeutic wrap and consumer (FC #1) IVC. Guardian had concerns of if she was going to return to Oakwood or what the plan would be after IVC. Guardian wanted to speak with therapist. transferred call to therapist." - 12/08/25 at 1:36pm - "Consumer Affairs Coordinator notified guardian of IVC. Sheriff picked her up at 1:36pm." - ...

Deficiency cited, complaint and follow-up survey : V 366} 27G .0603 Incident Response Requirements

Based on record review and interviews, the facility failed to implement written policies governing their response to level II incidents. The findings are: Finding #1: Review on 11/18/25 of client #33's record revealed: - Admission date of 05/29/25. - Diagnoses of Oppositional Defiant Disorder OAKWOOD TREATMENT CENTER na (ODD), Anxiety Disorder Unspecified and Attention-Deficit Hyperactivity Disorder (ADHD)-Unspecified. - Only 1 level II incident report for 3 restrictive interventions on 11/13/25. Review on 11/18/25 of the facility restrictive intervention log for client #33 revealed: - Date of intervention: 11/13/25. - Time of intervention: 5:42pm. - Duration of intervention: 25 minutes. - Emergency Safety Interventions (ESI) from 5:42pm until 5:52pm, 5:55pm until 6pm and 6:04pm until 6:12pm. Review on 11/18/25 of a level Il North Carolina Incident Response Improvement System (IRIS) report for client #33 revealed: - Date of incident: 11/13/25. - Time of incident: 6:30pm. - Provider Comments; "Consumer has 3 wraps within the same hour which totaled 25 minutes." - "Per staff- consumer became upset due to a cancelled home visit. Despite staff trying to verbally de-escalate the situation. The consumer the consumer became aggressive kicking holes in the walls and punching the walls. Consumer was placed in an ESI. Upon removal consumer continued being aggressive towards staff hitting staff and kicking staff. Consumer was placed in a second ESI. Upon release he became aggressive ...

Deficiency cited, complaint and follow-up survey : V 367| 27G .0604 Incident Reporting Requirements

Based on record review and interview, the facility failed to notify the Local Management Entity/Managed Care Organization (LME/MCO) of level Il incidents as required. The findings are: Finding #1: Review on 11/18/25 of client #33's record revealed: - Admission date of 05/29/25. - Diagnoses of Oppositional Defiant Disorder (ODD), Anxiety Disorder Unspecified and Attention-Deficit Hyperactivity Disorder (ADHD)-Unspecified. - Only 1 level II IRIS incident report was submitted as required.for the 3 restrictive interventions on 11/13/25. Review on 11/18/25 of the facility restrictive intervention log for client #33 revealed: - Date of intervention: 11/13/25. - Time of intervention: 5:42pm. - Duration of intervention: 25 minutes. - Emergency Safety Interventions (ESI) from 5:42pm until 5:52pm, 5:55pm until 6pm and 6:04pm until 6:12pm. Review on 11/18/25 of a level Il North Carolina Incident Response Improvement System (IRIS) report for client #33 revealed: - Date of incident: 11/13/25. - Time of incident: 6:30pm. - Provider Comments; "Consumer has 3 wraps within the same hour which totaled 25 minutes." - "Per staff- consumer became upset due to a cancelled home visit. Despite staff trying to verbally de-escalate the situation. The consumer the consumer became aggressive kicking holes OAKWOOD TREATMENT CENTER na in the walls and punching the walls. Consumer was placed in an ESI. Upon removal consumer continued being aggressive towards staff hitting staff and kicking staff. Consumer ...

Deficiency cited, annual, complaint, and follow-up survey : V 366] 27G .0603 Incident Response Requirements

Based on record review and interviews, the acility failed to implement written policies governing their response to Level incidents as required. The findings are: Review on 5/28/25 of client #5's record revealed: -Date of admission: 3/15/25 -Diagnoses: Major Depressive Disorder-Moderate, Disruptive Mood Dysregulation Disorder, Reaction to Severe Stress and Attention Deficient Hyperactivity Disorder. -Nursing Progress Notes: 3/27/25: "Nursing was called to come assess consumer after being beat up by another OAKWOOD TREATMENT CENTER na consumer. When nursing arrived at house it was noticed consumer had been stomped on around his neck and head. Consumer stated his neck was hurting. Neuro (Neurological) check done and A/Ox4 (Alert and Orient times 4), PERRLA (pupils are equal, round and reactive to light and accommodation). Consumer cleaned up, Neosporin applied to cuts, pictures taken for documentation, AOC (Authorized Operations Contact) called, [Physican] and DON (Director of Nursing) made aware. [Guardian] called at 18:33 and made aware. Patient left for ED (Emergency Department) around 18:50." 3/30/25: "Consumer was fighting with other consumers. Fine scratch and redness noted under right eye. Ice pack applied. Consumer moved to A house to stop fighting." 4/1/25: "this nurse called to assess consumer following fight with peers. Consumers c/o (chief complaint) nose pain and being hit in the back. On assessment nose aligned properly with swelling to bridge. No discoloration ...

Deficiency cited, annual, complaint, and follow-up survey : V 315 27G .1902 Psych. Res. Tx. Facility - Staff ;

Based on record reviews and interviews, the facility failed to maintain an approved waiver of Rule 10A NCAC 27G .1902 (e) to ensure compliance with providing 24-hr onsite coverage by a registered nurse (RN). Review on 08/21/24 of Division of Health Service Regulation (DHSR) records for the facility revealed: - No current approval waiver of Rule 10A NCAC 27G.1902 (e). - The last approved waiver for Rule 10A NCAC 276.1902 (e) was valid until December 31, 2022. Review on 08/20/24 of a Plan of Correction completed by the Chief Operating Officer (COO) implernented on 06/15/24 revealed: - "NOVA always takes steps to ensure that the PRTF has adequate nursing staffing to maintain the health and safety of the children we serve. [COO Name]. COO, will contact our home LME (Local Management Entity) [LME] to request a waiver to 10A NCAC 27G .1902. We have been successful in receiving this waiver in past years. [COO Name], COO will communicate with [LME], and request a waiver that will allow NOVA to staff all three facilities on NOVA' s PRTF campus with 4 RN, minimally. Once the waiver is in place [Director of Nursing (DON), Director of Nursing will ensure that PRTF shall provide 24 hour on-site coverage by a registered nurse." Review on 08/21/24 of a letter by the COO if continuation sheet 2 of 6 MHL054-126 Be WING 08/21/2024 T i addressed to the Local Management Entity/Managed Care Organization (LME/MCO) and dated 06/12/24 revealed: i - "To Whom it May Concern, NOVA Behavioral Health ...

Deficiency cited, annual, complaint, and follow-up survey : V 315) 27G .1902 Psych. Res. Tx. Facility - Staff

Based on record reviews and interviews, the facility failed to maintain an approved waiver of Rule 10A NCAC 27G .1902 (e) to ensure compliance with providing 24-hr onsite coverage by a registered nurse (RN). Review on 08/21/24 of Division of Health Service Regulation (DHSR) records for the facility revealed: - No current approval waiver of Rule 10A NCAC 27G.1902 (e). - The last approved waiver for Rule 10A NCAC. 27G.1902 (e) was valid until December 31, 2022. Review on 08/20/24 of a Plan of Correction completed by the Chief Operating Officer (COO) implemented on 06/15/24 revealed: - "NOVA always takes steps to ensure that the PRTF has adequate nursing staffing to maintain the health and safety of the children we serve. [COO Name], COO, will contact our home LME (Local Management Entity) [LME] to request a waiver to 10A NCAC 27G .1902. We have been successful in receiving this waiver in past years. [COO Name], COO will communicate with [LME], and request a waiver that will allow NOVA to staff all three facilities on NOVA' s PRTF campus with 1 RN, minimally. Once the waiver is in place, [Director of Nursing (DON), Director of Nursing will ensure that PRTF shall provide 24 hour on-site coverage by a registered nurse." Review on 08/21/24 of a letter by the COO PROVIDER'S PLAN OF CORRECTION (x5) addressed to the Local Management Entity/Managed Care Organization (LME/MCO) and dated 06/12/24 revealed: - "To Whom it May Concern, NOVA Behavioral Health operates three licensed ...

Deficiency cited, complaint and follow-up survey : V 315) 27G .1902 Psych. Res. Tx. Facility - Staff

Based on record reviews and interviews, the facility failed to maintain an approved waiver of Rule 10A NCAC 27G .1902 (e) to ensure compliance with providing 24-hr onsite coverage by a registered nurse (RN). Review on 05/16/24 of Division of Health Service Regulation (DHSR) records for the facility revealed: - No current approval waiver of Rule 10A NCAC 27G.1902 (e). - The last approved waiver for Rule 10A NCAC. 27G.1902 (e) was valid until December 31, 2022 Review on 05/16/24 of an approval of waiver sent to the previous facility program Director and dated 03/25/22 revealed - "RE: Approval of Request for Renewal of Waiver of Rule 10A NCAC 27G.1902 (e) for NOVA, Inc, [Sister] Facility, MHL-054-125, Oakwood Facility, MHL-054-126, [Sister] Facility, MHL-054-159, [Local] County...Pursuant to your request contained in your letter dated March 9, 2022, which was received March 9, 2022 and after review by our staff, have determined that the request for waiver be approved for licensure year 2022. This is based on delegation of authority given to me by [Director], Director of the Division of Health Service Regulation, on April 23, 2018. Rule 10A NCAC 27G.1902(e) provides, "[t]he PRTF shall provide 24 hour on-site coverage by a registered nurse." Renewal of the waiver will allow the facility to continue to utilize one RN position per shift to provide twenty-four hour on-site coverage for the three PRTF facilities that are in close proximity to each other. hereby approve your request ...

Deficiency cited, annual and complaint survey : V 315) 27G .1902 Psych. Res. Tx. Facility - Staff

Based on record reviews, observation and interviews the facility failed to ensure at least 2 direct care staff were present with every 6 children or adolescents at all times. The findings are: Review on 10/12/23 of the facility "Residential Treatment Plan (Scope of Service) Psychiatric Residential Treatment Facility (PRTF)" policy and procedure effective 01/01/16 revealed: - "Purpose: To comply with Section 10A NCAC 27G .1900, of the Rules for MH (Mental Health)/DD (Developmental Disability)/SA (Substance Abuse) Facilities and Services Clinical Policy No. 8D-1 of the Division of Medical Assistance, and applicable national accreditation standards." - "Personnel...A compliment of well-trained Paraprofessional Staff, provide direct supervision and services for Consumers, consistent with Person Centered Plans and the [Program] evidence-based model. All Paraprofessional Staff are trained in First Aid, CPR (Cardiopulmonary Resuscitation), emergency equipment use, North Carolina Interventions and CPI (Crisis Prevention Institute). NOVA maintains a minimum Staff to Consumer ratio of 1:3." Review on 10/12/23 of client #5's record revealed: - 15 year old female. - Admission date of 05/10/23. - Diagnoses of Post-Traumatic Stress Disorder and Conduct Disorder. Review on 10/12/23 of staff #1's personnel record revealed: - Date of hire 07/31/23. - Paraprofessional. Observation on 10/12/23 at approximately 9:46am revealed: - Client #5 and staff #1 entered the facility (D). - No other staff ...