Renewing Grace Residential Home

Deficiency cited, annual and follow-up survey : V 519} 27E .0104(e3-7) Client Rights - Sec. Rest. & ITO

Based on record reviews and interview the facility failed to develop and implement policy and procedures for restrictive interventions as required. The findings are: Review on 02/20/26 of the facility policy for restrictive interventions effective 1/15/26 revealed the following requirements were not included: -The process for identifying, training, assessing competence of facility employees who may authorize and implement restrictive interventions. -The duties and responsibilities of responsible professionals regarding the use of restrictive interventions. -The person responsible for documentation when restrictive were used. -The person responsible for the notification of others when restrictive interventions are used. Interview 02/20/26 the Director/Qualified Professional stated: -The restrictive intervention policy was revised in -The current policy would be reviewed to ensure it reflected the required language for restrictive interventions.

Deficiency cited, annual and follow-up survey : V 525} 27E .0104(e17) Client Rights - Sec. Rest. & ITO

Based on record review and interviews, the acility failed to maintain a restrictive intervention log with debriefing and planning conducted with staff. The findings are: Review on 02/19/26 of client #1's record revealed: -13 year old male. -Admission date of 10/13/25. -Diagnoses of Disruptive Mood Dysregulation Disorder, Attention Deficit Hyperactivity Disorder and Mild Intellectual Developmental Disability. Review on 02/19/26 and 02/20/26 of the restrictive intervention log for client #1 revealed: 12/26/25 at 3:40pm -5 minute standing restraint. -No documentation of debriefing with staff. 12/08/25 at 10:45am -1 minute standing restraint. -No documentation of debriefing with staff. 11/22/25 at 2:45pm -1 minute standing restraint. -No documentation of debriefing with staff. Interview on 02/19/26 and 02/20/26 the Executive Director stated: -She served as the Qualified Professional for the facility. -She completed the documentation when restraints were used at the facility. -Staff were debriefed after every restraint. -She was not able to locate the staff debriefing for client #1's restrictive interventions on 12/26/25, 12/08/25 and 11/22/25.

Deficiency cited, annual and follow-up survey : V519

person responsible for the Based on record reviews and interview the facility notification of others when failed to develop and implement policy and «dines 7 . procedures for restrictive interventions as Tre tadite interventions are used. required. The findings are: The facility policy will be revised to Review on 02/20/26 of the facility policy for include all necessary restrictive interventions effective 1/15/26 revealed companents. Executive Director the following requirements were not included: : ; -The process for identifying, training, assessing will ro monthly. competence of facility employees who may authorize and implement restrictive interventions. -The duties and responsibilities of responsible professionals regarding the use of restrictive Can eT {f continuation sheet 3 of ia i i interventions. -The person responsible for documentation when restrictive were used. -The person responsible for the notification of others when restrictive interventions are used. Interview 02/20/26 the Director/Qualified Professional stated: -The restrictive intervention policy was revised in -The current policy would be reviewed to ensure it reflected the required language for restrictive interventions.

Deficiency cited, annual and follow-up survey : V 525

Based on record review and interviews, the facility failed to maintain a restrictive intervention log with debriefing and planning conducted with staff. The findings are: Review on 02/19/26 of client #1's record revealed: -13 year old male. -Admission date of 10/13/25. -Diagnoses of Disruptive Mood Dysregulation Disorder, Attention Deficit Hyperactivity Disorder and Mild Intellectual Developmental Disability. Review on 02/19/26 and 02/20/26 of the restrictive intervention log for client #1 revealed: 12/26/25 at 3:40pm -5 minute standing restraint. -No documentation of debriefing with staff. 12/08/25 at 10:45am -1 minute standing restraint. -No documentation of debriefing with staff. 11/22/25 at 2:45pm

Deficiency cited, annual and complaint survey : V 132} G.S. 131E-256(G) HCPR-Notification,

Based on record reviews and interviews, the facility failed to ensure the Health Care Personnel Registry (HCPR) was notified of all allegations against health care personnel and failed to ensure all alleged allegations were investigated for 4 of 13 audited current staff (Qualified Professional (QP) #2, staff #5, staff #6, staff #11) and 3 of 5 audited Former Staff (FS) (#12, #13, #14) of. The findings are: Review on 09/07/23 of the North Carolina Incident Response Improvement System (IRIS) for July 1, 2023 thru September 7, 2023 revealed no level Ill reports submitted by the facility. Review on 09/07/23 of facility records revealed no documentation the HCPR was notified of an allegation of abuse against staff #5 #6, #11, Qualified Professional (QP) #2 and former staff (FS) #12, #13, and #14. Review on 08/24/23 of client #1's record revealed: -15 year old male. -Admission date of 06/16/23. -Diagnoses of Adjustment Disorder, with mixed disturbance of emotions and conduct, Oppositional Defiant Disorder and Mild Intellectual Developmental Disability. Review on 08/24/23 of client #5's record revealed: -13 year old male. -Admitted on 5/6/23. -Diagnoses of Disruptive Mood Dysregulation Disorder, Conduct Disorder, childhood onset type, Intellectual Developmental Disability (IDD), Mild, Child Physical Abuse, Child Psychological Abuse and Child Neglect. Finding #1: Review on 08/24/23 of an incomplete facility level incident report for client #5 revealed: -Date and time of incident ...

Deficiency cited, annual and complaint survey : V 366

Based on record reviews and interviews, the facility failed to implement written policies governing their responses to level incidents. The findings are: Finding #1: Review on 08/24/23 of client #1's record revealed: -15 year old male. -Admission date of 06/16/23. -Diagnoses of Adjustment Disorder, with mixed disturbance of emotions and conduct, Oppositional Defiant Disorder and Mild Intellectual Developmental Disability. Review on 09/07/23 of client #1's level facility incident reports revealed the following with no description of how these types of incidents may have been prevented or may be prevented in the future as well as any corrective measures that have been or will be put in place as a result of the incidents. -07/31/23 at 9:30am-verbal and physical aggression and property destruction, 07/28/23 at 8:30pm-verbal and physical aggression, 07/25/23 at 7:30pm-verbal and physical aggression, 07/25/23 at 7:05pm-verbal and physical aggression and property destruction, 08/17/23 at 9:00am-verbal and physical aggression, 08/05/23 at 5:00pm-verbal and physical aggression and elopement. Finding #2: Review on 08/29/23 of client #3's record revealed: -12 year old male. -Admission date of 05/02/23. -Conduct Disorder, Attention Deficit Hyperactivity Disorder combined and Disruptive Mood Dysregulation Disorder (DMDD). Review on 09/07/23 of client #3's level facility incident reports revealed the following with no description of how these types of incidents may have been prevented or ...

Deficiency cited, annual and complaint survey : V 367] 27G .0604 Incident Reporting Requirements

Based on record reviews and interviews, the facility failed to ensure incident reports were submitted to the Local Management Entity (LME)/Managed Care Organization (MCO) within 72 hours as required. The findings are: Review on 09/7/23 of the North Carolina Incident Response Improvement System (IRIS) for July 1, 2023 thru September 7, 2023 revealed no level Ill reports submitted by the facility. Review on 08/24/23 of client #1's record revealed: -15 year old male. -Admission date of 06/16/23. -Diagnoses of Adjustment Disorder, with mixed disturbance of emotions and conduct, Oppositional Defiant Disorder and Mild Intellectual Developmental Disability. Review on 08/24/23 of client #5's record revealed: -13 year old male. -Admitted on 05/6/23. -Diagnoses of Disruptive Mood Dysregulation Disorder, Conduct Disorder, childhood onset type, Intellectual Developmental Disability (IDD), Mild, Child Physical Abuse, Child Psychological Abuse and Child Neglect. Finding #1: Review on 08/24/23 of an incomplete facility level incident report for client #5 revealed: -Date and time of incident: 07/20/23 at 8:30pm. -Description of incident/Accident: "[Client #5] started to get aggressive towards 2 other clients. Putting his arms around their necks, stating he was going to kill them. We attempted to calm him down for about 10 min (minutes) but he just kept escalating to more aggressive behavior physically to the same 2 clients. Staff (unknown staff) decided to remove [Client #5] to his room to ...

Deficiency cited, annual and complaint survey : V 512

Based on record reviews and interview the facility failed to develop and implement policy and procedures for restrictive interventions as required. The findings are: Review on 08/25/23 of the facility policy for restrictive interventions revealed the following requirements were not included: -The process for identifying, training, assessing competence of facility employees who may authorize and implement restrictive interventions. -The duties and responsibilities of responsible professionals regarding the use of restrictive interventions. -The person responsible for documentation when restrictive were used. -The person responsible for the notification of others when restrictive interventions are used. -The person responsible for checking the client's physical and psychological well-being and assessing the possible consequences of the use of a restrictive intervention. -Procedures for documentation if a client had a physical disability or has had surgery that would make affected nerves and bones sensitive to injury. -Procedures for the identification and documentation of alternative emergency procedures, if needed. Interview 09/05/23 the Residential Director/Crisis Prevention Institute Instructor stated: -The restrictive intervention policy was revised in -The current policy did not reflect the required language for restrictive interventions.

Deficiency cited, annual and complaint survey : V 521] 27E .0104(e9) Client Rights - Sec. Rest. & ITO Vv 521

Based on record reviews and interviews, the facility failed to ensure the necessary documentation was in the client record when a restrictive intervention was utilized for 3 of 3 restrained clients (#1, #3 and #5). The findings are: Finding #1: Review on 08/24/23 of client #1's record revealed: -15 year old male. -Admission date of 06/16/23. -Diagnoses of Adjustment Disorder, with mixed disturbance of emotions and conduct, Oppositional Defiant Disorder and Mild Intellectual Developmental Disability. -No documentation of a description of the debriefing and planning with the client and the legally responsible person to reduce the probability of the future use of restrictive interventions. Review on 09/07/23 of client #1's level facility incident reports revealed: -Client #1 had been placed in a "hold", "restrain" or "CPI" (Crisis Prevention Institute) on 07/08/23 at 5:00pm, 07/31/23 at 9:30am, 7/28/23 at 8:30pm, 07/25/23 at 7:30pm, 07/25/23 at 7:05pm, 08/17/23 at 9:00am, 08/05/23 at 5:00pm Finding #2: Review on 08/29/23 of client #3's record revealed: -12 year old male. -Admission date of 05/02/23. -Conduct Disorder, Attention Deficit Hyperactivity Disorder combined and Disruptive Mood Dysregulation Disorder -No documentation of a description of the debriefing and planning with the client and the legally responsible person to reduce the probability of the future use of restrictive interventions. Review on 09/07/23 of client #3's level facility incident reports revealed ...

Deficiency cited, annual and complaint survey : V 524] 27E .0104(e12-16) Client Rights - Sec. Rest. &

Based on record reviews and interviews, the facility failed to notify the guardian immediately following a restrictive intervention or members of

Deficiency cited, annual and complaint survey : V 525

Based on record review and interviews, the facility failed to maintain a restrictive intervention log. The findings are: Review on 08/24/23 of facility records revealed no restrictive intervention log. Interview on 08/24/23 the Lead Qualified Professional (QP) stated: -She had started to work at the facility approximately 3 weeks ago. -She had not seen a restrictive intervention log. Interview on 09/05/23 the Residential Director/Crisis Prevention Institute Instructor stated: -A restraint log had been completed in the past. -She was not aware of a current restraint log. -A restraint log should be maintained for restrictive interventions.