raw_content:
Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual and follow up survey was completed
on September 10, 2024. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 8 and has a current
census of 8. The survey sample consisted of
audits of 3 current clients.
V 118| 27G .0209 (C) Medication Requirements Vv 118

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

‘A) client's name;

B) name, strength, and quantity of the drug;

C) instructions for administering the drug;

D) date and time the drug is administered; and
(E) name or initials of person administering the

(
(
(
(

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

6808 ERLI11

TITLE

(X6) DATE

If continuation sheet 1 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/16/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
09/10/2024

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 Vv 118

drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

This Rule is not met as evidenced by:

Based on record reviews, interviews, and
observation, the facility failed to ensure
medications were administered on the written
order of a physician and that MARs were kept
current affecting 3 of 3 audited clients (#1, #2,
#3). The findings are:

Reviews on 9/3/24 and 9/4/24 of Client #1's
record revealed:
-Date of admission: 5/28/24.
-Age: 16 years old.
-Diagnoses: Other Specified Disruptive,
Impulsive-Control and Conduct Disorder; Major
Depressive Disorder, Recurrent Episode, Mild;
Attention Deficit Hyperactivity Disorder (ADHD),
Combined Type.
-Physician orders dated 4/15/24:
-Lamotrigine (mood) 100 milligram (mg) 1
tablet (tab) twice daily.
-Guanfacine (ADHD) 2mg 1 tab twice daily.
-Trazodone 100mg (sleep) 1 tab at bedtime.
-Albuterol hydrofluoroalkane (HFA) 90
micrograms (mcg)/actuation/inhaler inhale 2 puffs
every 6 hours as needed (PRN) for wheezing.
-Standing Physician orders for over the counter
(OTC) medications dated 5/29/24 to follow
manufacturer's instructions for:

Division of Health Service Regulation
STATE FORM

6809

ERLI11

If continuation sheet 2 of 16

Division of Health Service Regulation

PRINTED: 09/16/2024
FORM APPROVED

-Calcium Carbonate (Heartburn) - no strength
identified.

-Hydrocortisone cream/Calamine (insect bite,
poison ivy) - no strength identified.

-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.

-Diphenhydramine (itching and allergies) - no
strength identified.

-Guaifenesin (chest congestion) 400mg.

-Generic mouthwash (oral hygiene).

Review on 9/4/24 of Client #1's MARs from
6/1/24-9/3/24 revealed:

-Lamotrigine not initialed as administered on
7/11/24 and 8/10/24.

-Intuniv not initialed as administered on
7/11/24 and 8/10/24.

-Trazodone not initialed as administered on
7/11/24.

-"Inhaler" initialed as administered on
6/11/24, 6/26/24, 7/25/24 but no documentation of
strength or quantity administered.

-OTC medications initialed as administered on
the back of the MAR:

-"Antacid" initialed as administered on 8/9/24
but no documentation of strength or quantity
administered.

-"Itch cream" initialed as applied on 6/27/24,
8/3/24 and 8/19/24 but no documentation of
strength applied.

-lbuprofen initialed as administered on
7/13/24, 8/8/24 and 8/20/24 but no
documentation of strength or quantity
administered and on 7/14/24-7/16/24 and 8/4/24
but no documentation of quantity administered.

-Diphenhydramine initialed as administered
once with no date and on 7/3/24 but no
documentation of strength administered.

-Guaifenesin initialed as administered on
6/18/24 but no documentation of strength

Division of Health Service Regulation

STATE FORM

6808 ERLI11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 2 Vv 118

If continuation sheet 3 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL014-006

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

administered.

-Mouthwash initialed as administered on
8/2/24, 8/5/24, 8/6/24, 8/8/24, 8/9/24, 8/12/24-
8/14/24, 8/21/24, 8/23/24, and 8/26/24-8/30/24
but no documentation of quantity administered.

Interview on 9/3/24 with Client #1 revealed:
-"...staff always give me my meds (medications)."
-"If | have a headache I'll ask staff for something
(medication)."

Reviews on 9/3/24 and 9/4/24 of Client #2's
record revealed:
-Date of admission: 12/26/23.
-Age: 17 years old.
-Diagnoses: Conduct Disorder, High Risk Sexual
Behaviors.
-Physician orders:
-2/20/24:

-Vitamin D3 (bone strength) 50
micrograms (mcg) 1 capsule (cap) every
morning.

-Melatonin (sleep) 5mg 1 tab at bedtime.

-2/27124:

-Loratadine (allergies) 10mg 1 tab daily.

-Fluticasone (allergies) 50mcg 1 spray in
each nostril twice daily.

-1/30/24:

-Ventolin HFA 90mcg 1 puff every 4-6

hours PRN.
1/23/24:

-Clindamycin/Benzoy| peroxide gel (acne)
1.2-5% apply 1 gram to skin daily as directed
(discard 60 days after fill date).

-7/311/24:

-Prevident toothpaste Sodium Fluoride
(cavities) twice daily.

-Mupirocin (skin infection) 2% ointment
apply to affected areas twice daily for 10 days.
-Standing Physician orders dated 1/4/24 to follow

Division of Health Service Regulation

STATE FORM

6809

ERLI11

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 3 Vv 118

If continuation sheet 4 of 16

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY

manufacturer's instructions for:

-Diphenhydramine (itching and allergies) - no
strength identified.

-Bismuth subsalicylate (diarrhea) - no
strength identified.

-Guaifenesin (chest congestion) 400mg.

-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.

-Polysporin ointment (triple
antibiotic/Bacitracin zinc ointment) (abrasions).

-Rubbing alcohol (abrasions) - no strength
identified.

-Hydrogen peroxide (abrasions).

Review on 9/4/24 of Client #2's MARs from
6/1/24-9/3/24 revealed:

-Vitamin D3 not initialed as administered on
8/6/24.

-Melatonin not initialed as administered on
7/29/24.

-Loratadine not initialed as administered on
8/19/24 and 8/24/24.

-Fluticasone was coded as "C" (medication
not in the facility) on 8/5/24-8/9/24 for the morning
doses but not documented as not in the facility
8/5/24-8/9/24 for the evening doses.

-Fluticasone not initialed as administered on
6/2/24 and 8/5/24 for the morning doses and on
6/1/24, 8/5/24-8/10/24, 8/23/24, 8/25/24 and
8/28/24 for the evening doses (14 doses missed).

-"Inhaler" initialed as administered on the
back of the MAR on 7/11/24, 7/28/24, 8/3/24,
8/17/24, 8/19/24, 8/26/24, and 8/30/24 but no
documentation of strength or quantity
administered.

-Clindamycin not initialed as applied on
6/1/24, 7/13/24, 8/9/24, 8/10/24, 8/23/24, and
8/25/24 and initialed as applied twice on 8/1/24
and 8/2/24.

-Prevident toothpaste not initialed as

Division of Health Service Regulation

STATE FORM

6809

ERLI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 4 Vv 118

If continuation sheet 5 of 16

Division of Health Service Regulation

PRINTED: 09/16/2024
FORM APPROVED

quantity applied.

administered.

administered.

administered.

Division of Health Service Regulation
STATE FORM

administered on 8/1/24, 8/2/24, and 8/4/24 for the
morning doses and on 8/1/24, 8/3/24, 8/13/24,
8/26/24, and 8/30/24 for the evening doses.
-Mupirocin not initialed as applied on 8/1/24-
8/7/24 for the morning and evening doses and on
8/8/24-8/10/24 for the evening doses.
-OTC medications initialed as administered on
the back of the MAR:
-Rubbing alcohol initialed as applied on
7/28/24 but no documentation of strength or

-Diphenhydramine initialed as administered
on 7/1/24 but no documentation of strength
administered and on 6/3/24, 6/5/24, and 6/23/24
but no documentation of strength or quantity

-Bismuth subsalicylate initialed as
administered on 6/4/24 and 7/28/24 but no
documentation of strength or quantity

-Guaifenesin 400mg initialed as administered
on 6/17/24 but no documentation of quantity

-lbuprofen initialed as administered on
6/30/24 and 7/1/24 but no documentation of
quantity administered, and on 7/27/24 but no
documentation of strength administered.

-Acetaminophen initialed as administered on
7/7/24, 7/14/24, and 7/15/24 but no
documentation of quantity administered, and on
7/5/24 and 7/27/24 but no documentation of
strength or quantity administered.

-Triple antibiotic/bacitracin zinc ointment
initialed as applied on 6/24/24 and 8/2/24-8/7/24
but no documentation of strength applied.

Interview on 9/3/24 with Client #2 revealed:
-"...take my meds every day."

Reviews on 9/3/24 and 9/4/24 of Client #3's

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
V 118] Continued From page 5 Vv 118

6808 ERLI11

If continuation sheet 6 of 16

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
09/10/2024

record revealed:
-Date of admission: 5/19/23.
-Age: 15 years old.
-Diagnosis: Conduct Disorder, Adolescent-Onset
Type.
-Physician orders dated 4/3/24:

-Sertraline (mood) 50mg tab,1 tab every
morning.

-No Physician order for Triamcinolone 0.1%
Cream.
-Standing Physician orders dated 8/23/23 to
follow manufacturer's instructions for:

-Bismuth subsalicylate (diarrhea) - no
strength identified.

-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.

-Polysporin ointment (triple antibiotic
ointment) (abrasions).

-Rubbing alcohol (abrasions) - no strength
identified.

-Hydrogen peroxide (abrasions).

-Generic mouthwash (oral hygiene).

Review on 9/4/24 of Client #3's MARs from
6/1/24-9/3/24 revealed:

-Sertraline (Zoloft) 50mg tab, take 1 tab every
morning. Morning is crossed out and "night" is
handwritten in on the June and July MAR.
Sertraline not initialed as administered on 6/3/24
and 7/11/24.

-Triamcinolone 0.1% cream apply to affected
area(s) twice a day PRN typed on June and July's
MAR initialed as applied on 6/2/24-6/4/24, 6/8/24-
6/13/24, 6/15/24-6/17/24, 6/19/24, 6/25/24,
6/26/24, 6/28/24-6/30/24, 7/1/24-7/5/24, 7/8/24-
7/12/24, 7/16/24, 7/19/24, 7/24/24, and 7/31/24.

-Triamcinolone initialed as applied on the
back of the MAR on 8/2/24 and 8/4/24 but no
documentation of strength applied.

-OTC medications initialed as administered on

Division of Health Service Regulation
STATE FORM

6809

ERLI11

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 6 Vv 118

If continuation sheet 7 of 16

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY

the back of the MAR:

-Bismuth subsalicylate initialed as
administered on 6/3/24, 6/7/24, 6/8/24, 6/11/24,
6/12/24, 7/3/24, 7/10/24, 7/11/24, 7/18/24-
7/21/24, and 7/23/24-7/25/24 but no
documentation of strength or dosage
administered.

-lbuprofen initialed as administered on
6/1/14, 7/1/24, 8/12/24, 8/15/24, and 8/20/24 but
no documentation of strength or quantity
administered, on 6/4/24 but no documentation of
strength administered, and on 6/8/24, 6/26/24,
6/29/24 and 8/8/24 but no documentation of
quantity administered.

-Acetaminophen initialed as administered on
7/8/24 but no documentation of strength or
quantity administered.

-Triple antibiotic ointment initialed as applied
on 6/1/24 but no documentation of strength
applied.

-Mouthwash handwritten and initialed as
administered on 8/1/24, 8/7/24, 8/9/24, 8/14/24,
8/16/24, 8/20/24, and 8/23/24 but no
documentation of strength or quantity.

Observation on 9/3/24 at 2:57pm of Client #3's
medications revealed:

-Sertraline (Zoloft) 50mg tab, 1 tab every
morning, dispensed on 8/15/24.

Interview on 9/3/24 with Client #3 revealed:
-"..always take my meds."

Interviews on 9/3/24-9/5/24 with Staff #1
revealed:

-She was responsible for updating and checking
MARs and Physician orders.

-She was "just checking for medication errors and
that staff were signing the back (of the MARs)."
-Staff were supposed to look at MAR,

Division of Health Service Regulation

STATE FORM

6809

ERLI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 7 Vv 118

If continuation sheet 8 of 16

Division of Health Service Regulation

PRINTED: 09/16/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE, DATE

DEFICIENCY)

V 118] Continued From page 8

prescriptions and medications before pulling a
client's medication for administration.

-Review of the MARs and Physician orders are
"...part of my job...not as detailed as | should
have been...I'm the only one reviewing (the
MARs)."

-Did not catch the missing initialed as
administered dates on the MARs, "...| missed
it...on me, would be an oversight."

-She was not sure why the Sertraline instructions
for administering in the morning were crossed out
and "night" was handwritten in for June and July
MARs, "...| don't have an answer for that...when |
checked at the end of the month | didn't check for
that...which is on me."

-When she would notice a medication was not
initialed as administered she would ask the
clients if they got their meds, "...they would say
yes...staff just didn't mark it."

-She would check the client's medication to see if
it was given and if the number sequence on the
MAR was off, missing initials on the MAR were
and "oversight of the staff not writing it down
when they passed it (administered the med).

Interviews on 9/4/24 and 9/5/24 with the Director
revealed:

-The expectation was the Staff #1 reviewed the
MARs and meds for accuracy.

-There was "no oversight" after Staff #1 reviewed
and submitted the MAR to the facility's records
department at the end of each month.

-He changed the medication review process to
have a nurse review the MARs and medications
for the facility.

-"Once the MAR is transcribed by [Staff #1] it will
be check by RN (Registered Nurse) before used
in facility."

-The way staff will be trained in medication
administration will be "more in-depth...more

Division of Health Service Regulation
STATE FORM

V 118

6808 ERLI11

If continuation sheet 9 of 16

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 9 Vv 118
thorough" moving forward.
V 119| 27G .0209 (D) Medication Requirements Vv 119

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(d) Medication disposal:

(1) All prescription and non-prescription
medication shall be disposed of in a manner that
guards against diversion or accidental ingestion.
(2) Non-controlled substances shall be disposed
of by incineration, flushing into septic or sewer
system, or by transfer to a local pharmacy for
destruction. A record of the medication disposal
shall be maintained by the program.
Documentation shall specify the client's name,
medication name, strength, quantity, disposal
date and method, the signature of the person
disposing of medication, and the person
witnessing destruction.

(3) Controlled substances shall be disposed of in
accordance with the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

(4) Upon discharge of a patient or resident, the
remainder of his or her drug supply shall be
disposed of promptly unless it is reasonably
expected that the patient or resident shall return
to the facility and in such case, the remaining
drug supply shall not be held for more than 30
calendar days after the date of discharge.

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM

6809

ERLI11

If continuation sheet 10 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL014-006

PRINTED: 09/16/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
09/10/2024

Based on record reviews, interviews and
observation, the facility failed to dispose of
medications in a manner that guarded against
diversion or accidental ingestion affecting 3 of 3
audited clients (#1, #2, #3). The findings are:

Observation on 9/5/24 at 10:30am of Client #1's
medications revealed:

-Calcium Antacid 750 milligram (mg) tablets (tab)
with an expiration date of 6/2024.

Review on 9/5/24 of Client #1's August 2024
Medication Administration Record (MAR)
revealed:

-Calcium Antacid initialed as administered on
8/9/24.

Observation on 9/3/24 at 2:40pm of Client #2's
medications revealed:

-Melatonin 5mg tabs with an expiration date of
11/2023.

-Clindamycin 1.2-5% gel with a pharmacy label to
discard 60 days after the fill date dispensed
2/2124.

Reviews on 9/3/24 and 9/4/24 of Client #2's
June-September 2024 MAR revealed:
-Clindamycin initialed as applied on 6/2/24-9/2/24.
-Melatonin initial as administered on
6/1/14-9/2/24.

Observation on 9/5/24 at 11am of Client #3's
medications revealed:

-70% rubbing alcohol with an expiration date of
3/2024.

Review on 9/5/24 of Client #3's August 2024 MAR
revealed:

-70% rubbing alcohol initialed as applied on
8/2/24.

Division of Health Service Regulation
STATE FORM

6808 ERLI11

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 119) Continued From page 10 Vv 119

If continuation sheet 11 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

BURKWELL

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
09/10/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE.
CROSS-REFERENCED TO THE APPROPRIATE,
DEFICIENCY)

(xs)
COMPLETE
DATE

V 119) Continued From page 11

Interviews on 9/3/24 and 9/4/24 with Staff #1
revealed:

-She was "just checking for med (medication)
errors and that staff were signing the back (of the
MARs)" at the end of each month.

-No meds were administered to Client #2 from
the expired Melatonin bottle, "...it (Melatonin) was
just there (in the medication bin)."

-She would check the meds to see if it was
administered and if the number sequence on the
MAR was off, "...if they (staff) done a med error
the med count would of been off."

Interview on 9/5/24 with the local Pharmacist
revealed:

-There were "no adverse effects" of
administering/applying the following
medications/treatments which had expired:
Clindamycin, Melatonin, rubbing alcohol, Calcium
Antacid;

-Clindamycin "...just would lose it's effectiveness."

Interviews on 9/4/24 and 9/5/24 with the Director
revealed:

-The expectation was that Staff #1 reviewed the
meds for accuracy.

-There was "no oversight" after Staff #1 reviewed
the medications.

-He changed the medication review process to
have a nurse review the MARs and medications
for the facility each month.

-The way staff will be trained in medication
administration will be "more in-depth...more
thorough" moving forward.

V 123} 27G .0209 (H) Medication Requirements

10A NCAC 27G .0209 MEDICATION

Vv 119

V 123

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 12 of 16

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/16/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
09/10/2024

REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all medication
administration errors were reported immediately
to a physician or pharmacist affecting 1 of 3
audited clients (#2). The findings are:

Reviews on 9/3/24 and 9/4/24 of Client #2's
record revealed:

-Date of admission: 12/26/23.

-Age: 17 years old.

-Diagnoses: Conduct Disorder, High Risk Sexual
Behaviors.

-Physician order dated 2/27/24:

-Fluticasone 50 microgram (mcg) (allergies) 1
spray in each nostril twice daily.

Review on 9/3/24 of Client #2's August 2024
Medication Administration Record (MAR)
revealed:

-Fluticasone was coded as "C" (medication not in
the facility) on 8/5/24-8/9/24 for the morning
doses but not documented as not in the facility
8/5/24-8/9/24 for the evening doses.

Division of Health Service Regulation
STATE FORM

6809

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 12 Vv 123

If continuation sheet 13 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

BURKWELL

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
09/10/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE.
CROSS-REFERENCED TO THE APPROPRIATE,
DEFICIENCY)

(xs)
COMPLETE
DATE

V 123] Continued From page 13

Review on 9/4/24 of Client #2's medication error
reports revealed:

-No documentation of immediately reporting to a
physician or pharmacist for Client #2 not being
administered Fluticasone as scheduled on 8/5/24
morning and evening dose, 8/6/24 morning and
evening dose, and 8/7/24-8/9/24 evening dose.

Interview on 9/3/24 with Client #2 revealed:
-"...take my meds (medications) every day."
-Did not report missing any Fluticasone.

Interviews on 9/3/24 and 9/4/24 with Staff #1
revealed:

-She was "just checking for medication errors and
that staff were signing the back (of the MARs)" at
the end of each month.

-Code "C" written on MAR indicated the
medication was not available in the facility.

Interview on 9/6/24 with local Pharmacist
revealed:

-There were no adverse effects for an individual
missing their Fluticasone nasal spray from
8/5/24-8/10/24, "...doesn't really matter...|
wouldn't worry about it."

Interview on 9/4/24 with the Director revealed:
-The expectation was the Staff #1 reviewed meds
for accuracy.

-He will be changing the medication review
process to having a nurse review medications at
the facility.

V 736] 27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS
(c) Each facility and its grounds shall be

Division of Health Service Regulation
STATE FORM

V 123

V 736

6809

If continuation sheet 14 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/16/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
09/10/2024

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 14 V 736

maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to be maintained in safe manner. The
findings are:

Observation on 9/3/24 at 1:33pm of the facility's
interior revealed:

-3 out of 5 client bedrooms did not have a door to
their bedroom (bedroom #1, #3 and #5).

Interview on 9/3/24 with Client #1 revealed:
-Did not have a bedroom door.
-"Staff need to see us at all times..."

Interviews on 9/3/34 and 9/4/24 with Staff #1
revealed:

-She "believed" the bedroom doors were missing
due to property destruction from previous clients.
-The facility's maintenance man was supposed to
put the bedroom doors back on, "...our
maintenance man left...I didn't check behind and
make sure they were put on."

-"Can't answer why they (bedroom doors) have
not been put on (client bedroom)"

-The missing bedroom doors were in the
basement of the facility.

Interview on 9/4/24 with the Qualified
Professional (QP) revealed:

-Some of the bedroom doors were removed in
the last few years.

-"They (clients) have to be in eyesight at all times
except in the bathroom."

Interviews on 9/4/24 and 9/5/24 with the Director
revealed:

Division of Health Service Regulation
STATE FORM

6809

ERLI11

If continuation sheet 15 of 16

PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 15 V 736

-The bedroom doors were removed due to
supervision concerns "...this is a 24-hour
supervision home."

-"If they (clients) get their doors shut and
barricade themselves in there (bedroom) that
would be an issue."

-"Will put the doors back on (client bedrooms) if
we (facility) have to."

Division of Health Service Regulation
STATE FORM

6809

ERLI11

If continuation sheet 16 of 16


state: NC

facility_name: Burkwell

summary: Plan of Correction - MHLCS Annual and Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL014-006

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B, WING

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R

09/10/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD

BURKWELL

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

LENOIR, NC 28645

Vv 000

Vv 118

INITIAL COMMENTS

An annual and follow up survey was
completed on September 10, 2024.
Deficiencies were cited.

This facility is licensed for the following
service category: 10A NCAC 27G .1700
Residential Treatment Staff Secure for
Children or

Adolescents.

This facility is licensed for 8 and has a
current census of 8. The survey sample
consisted of audits of 3 current clients.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs
shall only be administered to a client on the
written order of a person authorized by law
to prescribe drugs.

(2) Medications shall be self-administered
by clients only when authorized in writing
by the client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered
nurse, pharmacist or other legally qualified
person and privileged to prepare and
administer medications. (4) A Medication
Administration Record (MAR) of all drugs
administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration.
The MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the
drug; (C) instructions for administering

v8

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE,

DEFICIENCY)

xs)
COMPLETE
DATE

—

RECEIVED
SEP 3 2024
BRB RMH Licensure Sect

Focus implemented a new standing order form.
This form will be trained on during the medication
class moving forward with all staff. All clients who
receive injections will be trained by a registered
nurse or pharmacist prior to administering
medications or injections. All staff retrained on
reading and understanding each medication and
administering as directed by pharmacist/physician.

All medications that are over the counter including
mouthwash, ibuprofen etc will be documented with
quantity and effectiveness. All staff will be
retrained on this new form to ensure compliance.

Staff re-trained to follow MARs and informed that
only changes on the MAR can only take place by
trained and approved personal. All MARs and
documentation will follow physician's orders.

All MARs and physicians orders to be reviewed and
compared monthly by contract Registered Nurse.

||

9/24/2024

9/24/2024

9/24/2024

9/24/2024

the drug;

(D) date and time the drug is administered;
and (E) name or initials of person
administering the

Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER'SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM &*ERL11 "continuation sheet 1 of 16

PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
B, WING .
MHLO14-006 09/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 'D PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 118 Continued From page 1 Vv 118

drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the
MAR file followed up by appointment or
consultation with a physician.

This Rule is not met as evidenced by:
Based on record reviews, interviews, and
observation, the facility failed to ensure
medications were administered on the
written order of a physician and that MARs
were kept current affecting 3 of 3 audited
clients (#1, #2, #3). The findings are:

Reviews on 9/3/24 and 9/4/24 of Client
#1's record revealed:
-Date of admission: 5/28/24.
-Age: 16 years old.
-Diagnoses: Other Specified Disruptive,
Impulsive-Control and Conduct Disorder;
Major Depressive Disorder, Recurrent
Episode, Mild; Attention Deficit Hyperactivity
Disorder (ADHD), Combined Type.
-Physician orders dated 4/15/24:
-Lamotrigine (mood) 100 milligram (mg) 1
tablet (tab) twice daily.
-Guanfacine (ADHD) 2mg 1 tab twice
daily. -Trazodone 100mg (sleep) 1 tab at
bedtime. -Albutero! hydrofluoroalkane
(HFA) 90
micrograms (mcg)/actuation/inhaler inhale 2
puffs every 6 hours as needed (PRN) for
wheezing. -Standing Physician orders for over
the counter (OTC) medications dated 5/29/24

to follow
manufacturer's instructions for:

Division of Health Service Regulation

If continuation sheet 2 of 16

STATE FORM “°° ERLI11
PRINTED: 09/16/2024
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A, BUILDING: COMPLETED
R

MHL014-006 B WING 09/10/2024

NAME OF PROVIDER OR SUPPLIER

BURKWELL
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

-Calcium Carbonate (Heartburn) - no
strength identified.

-Hydrocortisone cream/Calamine (insect
bite, poison ivy) - no strength identified.

-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.

-Diphenhydramine (itching and allergies) -
no strength identified.

-Guaifenesin (chest congestion) 400mg.

-Generic mouthwash (oral hygiene).

Review on 9/4/24 of Client #1's MARs
from 6/1/24-9/3/24 revealed:

-Lamotrigine not initialed as administered
on 7/11/24 and 8/10/24.

-Intuniv not initialed as administered on
7/11/24 and 8/10/24.

-Trazodone not initialed as administered
on 7/11/24.

-"Inhaler" initialed as administered on
6/11/24, 6/26/24, 7/25/24 but no documentation
of strength or quantity administered.

-OTC medications initialed as administered
on the back of the MAR:

-"Antacid" initialed as administered on
8/9/24 but no documentation of strength or
quantity administered.

-"Itch cream" initialed as applied on
6/27/24, 8/3/24 and 8/19/24 but no
documentation of strength applied.

-lbuprofen initialed as administered on
7/13/24, 8/8/24 and 8/20/24 but no
documentation of strength or quantity
administered and on 7/14/24-7/16/24 and
8/4/24 but no documentation of quantity
administered. -Diphenhydramine initialed as
administered once with no date and on
7/3/24 but no
documentation of strength administered.

-Guaifenesin initialed as administered on

6/18/24 but no documentation of strength

STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD

LENOIR, NC 28645

PREFIX

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD 8E
CROSS-REFERENCED TO THE APPROPRIATE ORE

(x5)
COMPLETE

Division of Health Service Regulation

STATE FORM °° ERLI11

Division of Health Service Regulation

If continuation sheet 3 of 16

PRINTED: 09/16/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLO014-006 B WING 09/10/2024

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 118 Continued From page 3

administered.

-Mouthwash initialed as administered on
8/2/24, 8/5/24, 8/6/24, 8/8/24, 8/9/24,
8/12/24- 8/14/24, 8/21/24, 8/23/24, and
8/26/24-8/30/24 but no documentation of
quantity administered.

Interview on 9/3/24 with Client #1 revealed:
-"._.staff always give me my meds
(medications)." -"If | have a headache I'll ask
staff for something (medication)."

Reviews on 9/3/24 and 9/4/24 of Client
#2's record revealed:
-Date of admission: 12/26/23.
-Age: 17 years old.
-Diagnoses: Conduct Disorder, High Risk
Sexual Behaviors.
-Physician orders:
-2/20/24:

-Vitamin D3 (bone strength) 50
micrograms (mcg) 1 capsule (cap) every
morning.

-Melatonin (sleep) 5mg 1 tab at bedtime.

-2/27/24:

-Loratadine (allergies) 10mg 1 tab daily.

-Fluticasone (allergies) 50mcg 1 spray in
each nostril twice daily.

-1/30/24:

-Ventolin HFA 90mcg 1 puff every 4-6

hours PRN.
-1/23/24:

-Clindamycin/Benzoyl peroxide gel (acne)
1.2-5% apply 1 gram to skin daily as
directed (discard 60 days after fill date).

-7131124:

-Prevident toothpaste Sodium Fluoride
(cavities) twice daily.

-Mupirocin (skin infection) 2% ointment
apply to affected areas twice daily for 10 days.
-Standing Physician orders dated 1/4/24 to
follow

Division of Health Service Regulation

STATE FORM ® ERLI11 If continuation sheet 4 of 16

PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
B. WING R
MHL014-006 3 Sl 09/10/2024

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD

BURKWELL

LENOIR, NC 28645

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 118

Continued From page 4 Vv 118

manufacturer's instructions for:
-Diphenhydramine (itching and allergies) -
no strength identified.
-Bismuth subsalicylate (diarrhea) - no
strength identified.
-Guaifenesin (chest congestion) 400mg.
-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.
-Polysporin ointment (triple
antibiotic/Bacitracin zinc ointment)
(abrasions). -Rubbing alcoho!
(abrasions) - no strength
identified.
-Hydrogen peroxide (abrasions).

Review on 9/4/24 of Client #2's MARs
from 6/1/24-9/3/24 revealed:

-Vitamin D3 not initialed as administered
on 8/6/24.

-Melatonin not initialed as administered on
7/29/24.

-Loratadine not initialed as administered
on 8/19/24 and 8/24/24.

-Fluticasone was coded as "C" (medication
not in the facility) on 8/5/24-8/9/24 for the
morning doses but not documented as not in
the facility 8/5/24-8/9/24 for the evening doses.

-Fluticasone not initialed as administered on
6/2/24 and 8/5/24 for the morning doses and
on 6/1/24, 8/5/24-8/10/24, 8/23/24, 8/25/24
and 8/28/24 for the evening doses (14 doses
missed). -"Inhaler" initialed as administered
on the
back of the MAR on 7/11/24, 7/28/24,
8/3/24, 8/17/24, 8/19/24, 8/26/24, and
8/30/24 but no documentation of strength
or quantity
administered.

-Clindamycin not initialed as applied on
6/1/24, 7/13/24, 8/9/24, 8/10/24, 8/23/24,
and 8/25/24 and initialed as applied twice
on 8/1/24 and 8/2/24.

-Prevident toothpaste not initialed as

Division of Health Service Regulation

Division of Health Service Regulation
STATE FORM & ERLI11 |f continuation sheet 5 of 16

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA,
IDENTIFICATION NUMBER:

B, WING

MHL014-006

PRINTED: 09/16/2024
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

NAME OF PROVIDER OR SUPPLIER.
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118 Continued From page 5 Vv 118

administered on 8/1/24, 8/2/24, and 8/4/24 for
the morning doses and on 8/1/24, 8/3/24,
8/13/24, 8/26/24, and 8/30/24 for the evening
doses.

-Mupirocin not initialed as applied on
8/1/24- 8/7/24 for the morning and evening
doses and on 8/8/24-8/10/24 for the evening
doses.

-OTC medications initialed as administered
on the back of the MAR:

-Rubbing alcohol initialed as applied on
7/28/24 but no documentation of strength
or quantity applied.

-Diphenhydramine initialed as
administered on 7/1/24 but no documentation
of strength administered and on 6/3/24,
6/5/24, and 6/23/24 but no documentation of
strength or quantity administered.

-Bismuth subsalicylate initialed as
administered on 6/4/24 and 7/28/24 but
no documentation of strength or
quantity
administered.

-Guaifenesin 400mg initialed as
administered on 6/17/24 but no documentation
of quantity administered.

-Ibuprofen initialed as administered on
6/30/24 and 7/1/24 but no documentation
of quantity administered, and on 7/27/24
but no documentation of strength
administered.

-Acetaminophen initialed as administered
on 7/7/24, 7/14/24, and 7/15/24 but no
documentation of quantity administered, and
on 7/5/24 and 7/27/24 but no documentation
of strength or quantity administered.

-Triple antibiotic/bacitracin zinc ointment
initialed as applied on 6/24/24 and
8/2/24-8/7/24 but no documentation of
strength applied.

Interview on 9/3/24 with Client #2
revealed: -"...take my meds every day."

Reviews on 9/3/24 and 9/4/24 of Client #3's

Division of Health Service Regulation

STATE FORM ®*ERLI11 |" continuation sheet 6 of 16

PRINTED: 09/16/2024
FORM APPROVED

Division of Health Service Regulation

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
B. WING Ri
MHL014-006 : 09/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

L

Vv 118 Continued From page 6

record revealed:
-Date of admission: 5/19/23.
-Age: 15 years old.
-Diagnosis: Conduct Disorder,
Adolescent-Onset Type.
-Physician orders dated 4/3/24:
-Sertraline (mood) 50mg tab,1 tab every
morning.
-No Physician order for Triamcinolone
0.1% Cream.
-Standing Physician orders dated 8/23/23
to follow manufacturer's instructions for:
-Bismuth subsalicylate (diarrhea) - no
strength identified.
-Acetaminophen or Ibuprofen (mild pain or
fever) 200 to 500mg.
-Polysporin ointment (triple antibiotic
ointment) (abrasions).
-Rubbing alcohol (abrasions) - no strength
identified.
-Hydrogen peroxide (abrasions).
-Generic mouthwash (oral hygiene).

Review on 9/4/24 of Client #3's MARs
from 6/1/24-9/3/24 revealed:

Sertraline (Zoloft) 50mg tab, take 1 tab
every morning. Morning is crossed out and
"night" is handwritten in on the June and July
MAR.

Sertraline not initialed as administered on
6/3/24 and 7/11/24.

-Triamcinolone 0.1% cream apply to affected
area(s) twice a day PRN typed on June and
July's MAR initialed as applied on
6/2/24-6/4/24, 6/8/24- 6/13/24, 6/15/24-6/17/24,
6/19/24, 6/25/24, 6/26/24, 6/28/24-6/30/24,
7/1124-7/5/24, 7/8/24- 7/12/24, 7/16/24,
7/19/24, 7/24/24, and 7/31/24. -Triamcinolone
initialed as applied on the

back of the MAR on 8/2/24 and 8/4/24 but

no documentation of strength applied.
ee ee

| | -OTC medications initialed as administered on il

Division of Health Service Regulation

STATE FORM ° ERLI11 Hf continuation sheet 7 of 16

PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
B. WING R
MHL014-006 09/10/2024

NAME OF PROVIDER OR SUPPLIER:
STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

BURKWELL
LENOIR, NC 28645

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 118 | Continued From page 7 Vv 118

the back of the MAR:

-Bismuth subsalicylate initialed as
administered on 6/3/24, 6/7/24, 6/8/24,
6/11/24, 6/12/24, 7/3/24, 7/10/24, 7/11/24,
7/18/24-

7/21/24, and 7/23/24-7/25/24 but no
documentation of strength or dosage
administered.

-lbuprofen initialed as administered on
6/1/14, 7/1/24, 8/12/24, 8/15/24, and 8/20/24
but no documentation of strength or quantity
administered, on 6/4/24 but no documentation
of strength administered, and on 6/8/24,
6/26/24, 6/29/24 and 8/8/24 but no
documentation of quantity administered.

-Acetaminophen initialed as administered
on 7/8/24 but no documentation of strength or
quantity administered.

-Triple antibiotic ointment initialed as
applied on 6/1/24 but no documentation of
strength applied.

-Mouthwash handwritten and initialed as
administered on 8/1/24, 8/7/24, 8/9/24,
8/14/24, 8/16/24, 8/20/24, and 8/23/24 but
no
documentation of strength or quantity.

Observation on 9/3/24 at 2:57pm of Client
#3's medications revealed:

-Sertraline (Zoloft) 50mg tab, 1 tab every
morning, dispensed on 8/15/24.

Interview on 9/3/24 with Client #3
revealed: -"...always take my meds."

Interviews on 9/3/24-9/5/24 with Staff #1
revealed:

-She was responsible for updating and
checking MARs and Physician orders.

-She was "just checking for medication errors
and that staff were signing the back (of the
MARs)." -Staff were supposed to look at MAR,

Division of Health Service Regulation
STATE FORM ® ER 14 !f continuation sheet 8 of 16

Division of Health Service Regulation

PRINTED: 09/16/2024
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL014-006 BaWING

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv118 Continued From page 8

prescriptions and medications before

pulling a client's medication for
administration.

-Review of the MARs and Physician orders
are "...part of my job...not as detailed as |
should have been...I'm the only one
reviewing (the MARs)."

-Did not catch the missing initialed as
administered dates on the MARs, "...|
missed it...on me, would be an oversight."
-She was not sure why the Sertraline
instructions for administering in the morning
were crossed out and "night" was handwritten
in for June and July MARs, "...1 don't have an
answer for that...when | checked at the end of
the month | didn't check for that...which is on
me."

-When she would notice a medication was

not initialed as administered she would ask
the clients if they got their meds, "...they
would say yes...staff just didn't mark it."

-She would check the client's medication to
see if it was given and if the number
sequence on the MAR was off, missing initials
on the MAR were and "oversight of the staff
not writing it down when they passed it
(administered the med).

Interviews on 9/4/24 and 9/5/24 with the
Director revealed:

-The expectation was the Staff #1 reviewed
the MARs and meds for accuracy.

-There was "no oversight" after Staff #1
reviewed and submitted the MAR to the
facility's records department at the end of
each month.

-He changed the medication review process
to have a nurse review the MARs and
medications for the facility.

-"Once the MAR is transcribed by [Staff #1] it
will be check by RN (Registered Nurse)
before used in facility."

-The way staff will be trained in

medication administration will be "more
in-depth... more

Division of Health Service Regulation

STATE FORM °ERLI11 lf continuation sheet 9 of 16

Division of Health Service Regulation

(X14) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHLO014-006

NAME OF PROVIDER OR SUPPLIER,

BURKWELL
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 9

thorough” moving forward.

V 119 | 27G .0209 (D) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(d) Medication disposal:

(1) All prescription and non-prescription
medication shall be disposed of in a manner
that guards against diversion or accidental
ingestion. (2) Non-controlled substances shall
be disposed of by incineration, flushing into
septic or sewer

system, or by transfer to a local pharmacy for
destruction. A record of the medication
disposal shall be maintained by the

program.

Documentation shall specify the client's

name, medication name, strength, quantity,
disposal date and method, the signature of
the person disposing of medication, and

the person

witnessing destruction.

(3) Controlled substances shall be disposed of
in accordance with the North Carolina
Controlled Substances Act, G.S. 90, Article 5,
including any subsequent amendments.

(4) Upon discharge of a patient or resident,
the remainder of his or her drug supply shall
be disposed of promptly unless it is
reasonably expected that the patient or
resident shall return to the facility and in

such case, the remaining drug supply shall
not be held for more than 30 calendar days
after the date of discharge.

PRINTED: 09/16/2024

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
B. WING R
: 09/10/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD

LENOIR, NC 28645

PREFIX
TAG

Vv 1139

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

COMPLETE
DATE

Focus Behavioral will implement a two person
disposal. All medications being disposed will be
logged on the sheet. This process will take place
with two administrative staff and or nurse when
available. Disposal sheet will be checked by the
Registered Nurse monthly.

9/24/2024

Group home manager, Quality Improvement, or 9/24/2024
Nursing will conduct periodic reviews of medication
passes to ensure the quality and accuracy of

medications being administered.

Group home manager to ensure that all medication | 9/24/2024
over the counter to be review monthly to ensure
that all medications are in date and will disposed of
properly according to protocol.

This Rule is not met as evidenced by:

Division of Health Service Regulation

STATE FORM ®ERLI11 |f continuation sheet 10 of 16

PRINTED: 09/16/2024

FORM APPROVED
STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL014-006 nia 09/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION Xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

v1i9 Continued From page 10 Vv 119

Based on record reviews, interviews and
observation, the facility failed to dispose of
medications in a manner that guarded
against diversion or accidental ingestion
affecting 3 of 3 audited clients (#1, #2, #3).
The findings are:

Observation on 9/5/24 at 10:30am of Client
#1's medications revealed:

-Calcium Antacid 750 milligram (mg) tablets
(tab) with an expiration date of 6/2024.

Review on 9/5/24 of Client #1's August
2024 Medication Administration Record
(MAR)

revealed:

-Calcium Antacid initialed as administered
on 8/9/24.

Observation on 9/3/24 at 2:40pm of Client
#2's medications revealed:

-Melatonin 5mg tabs with an expiration date

of 11/2023.

-Clindamycin 1.2-5% gel with a pharmacy label
to discard 60 days after the fill date dispensed
2/2/24.

Reviews on 9/3/24 and 9/4/24 of Client
#2's June-September 2024 MAR
revealed:

-Clindamycin initialed as applied on
6/2/24-9/2/24, -Melatonin initial as
administered on

6/1/14-9/2/24,

Observation on 9/5/24 at 11am of Client
#3's medications revealed:

-70% rubbing alcohol with an expiration date
of 3/2024.

Review on 9/5/24 of Client #3's August 2024
MAR revealed:

-70% rubbing alcohol initialed as applied

on 8/2/24.

| |

Division of Health Service Regulation
STATE FORM ® ERLI11 |f continuation sheet 11 of 16

Division of Health Service Regulation

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER: ‘A. BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHL014-006 B. WING

PRINTED: 09/16/2024
FORM APPROVED.

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Vv119 Continued From page 11 v 119

Interviews on 9/3/24 and 9/4/24 with Staff

#1 revealed:

-She was "just checking for med (medication)
errors and that staff were signing the back (of
the MARs)" at the end of each month.

-No meds were administered to Client #2 from
the expired Melatonin bottle, "...it (Melatonin)
was just there (in the medication bin)."

-She would check the meds to see if it was
administered and if the number sequence on
the MAR was off, "...if they (staff) done a med
error the med count would of been off."

Interview on 9/5/24 with the local

Pharmacist revealed:

-There were "no adverse effects" of
administering/applying the following
medications/treatments which had expired:
Clindamycin, Melatonin, rubbing alcohol,

Calcium Antacid;

-Clindamycin "...just would lose it's effectiveness."

Interviews on 9/4/24 and 9/5/24 with the
Director revealed:
-The expectation was that Staff #1 reviewed
the meds for accuracy.
-There was "no oversight" after Staff #1
reviewed the medications.
-He changed the medication review process
to have a nurse review the MARs and
medications for the facility each month.
-The way staff will be trained in
medication administration will be "more
in-depth...more thorough" moving
forward.

V 123 Vv 123

27G .0209 (H) Medication Requirements

410A NCAC 27G .0209 MEDICATION

Division of Health Service Regulation
STATE FORM % ERLIN1 |f continuation sheet 12 of 16
PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO014-006

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

TAG

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

LENOIR, NC 28645

BURKWELL
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 12

REQUIREMENTS
(h) Medication errors. Drug administration
errors and significant adverse drug reactions
shall be reported immediately to a physician
or

pharmacist. An entry of the drug administered
and the drug reaction shall be properly
recorded in the drug record. A client's refusal
of adrug shall be charted.

This Rule is not met as evidenced by:
Based on record reviews and interviews,
the facility failed to ensure all medication
administration errors were reported
immediately to a physician or pharmacist
affecting 1 of 3 audited clients (#2). The
findings are:

Reviews on 9/3/24 and 9/4/24 of Client
#2's record revealed:

-Date of admission: 12/26/23.

-Age: 17 years old.

-Diagnoses: Conduct Disorder, High Risk
Sexual Behaviors.

-Physician order dated 2/27/24:
-Fluticasone 50 microgram (mcg)
(allergies) 1 spray in each nostril twice
daily.

Review on 9/3/24 of Client #2's August

2024 Medication Administration Record
(MAR)

revealed:

-Fluticasone was coded as "C" (medication not
in the facility) on 8/5/24-8/9/24 for the morning
doses but not documented as not in the facility
8/5/24-8/9/24 for the evening doses.

|

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

All medication errors will be reported to the
Registered Nurse/Quality Improvement via email
for review in accuracy. Pharmacy will be contacted
on all medication eros. If there is no response from
pharmacist within 30 minutes, Registered Nurse
will be contacted.

Ql/Nursing will begin quarterly audits for MARs and
medications of all programs served to ensure
accuracy and improve medication administration.

Division of Health Service Regulation
STATE FORM © ERLI11 lf continuation sheet 13 of 16
PRINTED: 09/16/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER’ A. BUILDING COMPLETED
B, WING oe
MHL014-006 ‘ 09/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 123 Continued From page 13

Review on 9/4/24 of Client #2's medication
error reports revealed:

-No documentation of immediately reporting to
a physician or pharmacist for Client #2 not
being administered Fluticasone as scheduled
on 8/5/24 morning and evening dose, 8/6/24
morning and evening dose, and 8/7/24-8/9/24
evening dose.

Interview on 9/3/24 with Client #2
revealed: -"_take my meds
(medications) every day." -Did not report
missing any Fluticasone.

Interviews on 9/3/24 and 9/4/24 with Staff

#1 revealed:

-She was "just checking for medication errors
and that staff were signing the back (of the
MARs)" at the end of each month.

-Code "C" written on MAR indicated the
medication was not available in the facility.

Interview on 9/6/24 with local Pharmacist
revealed:

-There were no adverse effects for an
individual missing their Fluticasone nasal
spray from

8/5/24-8/10/24, "...doesn't really matter...1
wouldn't worry about it."

Interview on 9/4/24 with the Director revealed:
-The expectation was the Staff #1 reviewed
meds for accuracy.

-He will be changing the medication review

V 736 | process to having a nurse review medications
at the facility.

27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS
(c) Each facility and its grounds shall be

V 123

V 736

Focus Behavioral Health will reinstall all doors 9/24/2024

missing from bedrooms.

Division of Health Service Regulation

STATE FORM" ERL|11 |feontinuation sheet 14 of 16

Division of Health Service Regulation

PRINTED: 09/16/2024
FORM APPROVED

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHL014-006

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X3) DATE SURVEY
COMPLETED

R
09/10/2024

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
———

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 736 Continued From page 14 V 736

maintained in a safe, clean, attractive and
orderly manner and shall be kept free from
offensive odor.

This Rule is not met as evidenced by:
Based on observation and interview, the
facility failed to be maintained in safe
manner. The findings are:

Observation on 9/3/24 at 1:33pm of the
facility's interior revealed:

-3 out of 5 client bedrooms did not have a door
to their bedroom (bedroom #1, #3 and #5).

Interview on 9/3/24 with Client #1
revealed: -Did not have a bedroom door.
-"Staff need to see us at all times...”

Interviews on 9/3/34 and 9/4/24 with Staff
#1 revealed:

-She "believed" the bedroom doors were
missing due to property destruction from
previous clients. -The facility's maintenance
man was supposed to put the bedroom doors
back on, "...our

maintenance man left... didn't check behind
and make sure they were put on."

-"Can't answer why they (bedroom doors)
have not been put on (client bedroom)”
-The missing bedroom doors were in the
basement of the facility.

Interview on 9/4/24 with the Qualified
Professional (QP) revealed:

-Some of the bedroom doors were removed
in the last few years.

-"They (clients) have to be in eyesight at all
times except in the bathroom."

Interviews on 9/4/24 and 9/5/24 with the
Director revealed:

Division of Health Service Regulation
STATE FORI

Division of Health Service Regulation

M9 ERL|14 |feontinuation sheet 15 of 16

PRINTED: 09/16/2024

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL014-006 BL WING 09/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
1

V 736 Continued From page 15 V 736

-The bedroom doors were removed due to

supervision concerns "...this is a 24-hour

supervision home.”

-"If they (clients) get their doors shut and

barricade themselves in there (bedroom)

that would be an issue.”

-"Will put the doors back on (client

bedrooms) if we (facility) have to."

Division of Health Service Regulation

STATE FORM ®ERLI11 |f continuation sheet 16 of 16

Division of Health Service Regulation
Mental Health Licensure and Certification Section
Rule Violation and Client/ Staff Identifier List

Facility Name: Burkwell MHL Number: _ 014-006

Exit Date: 9/10/24 Surveyor(s): iii
EXIT PARTICIPANTS: [Director

COVID NOTIFICATION: In the event a COVID positive case is identified within 48
hours of a DHSR survey — the provider or DHSR should notify the other entity to
prevent possible continued exposures.

Rule Violation/Tag #/Citation Level: 10A NCAC 27G .0209 Medication Requirements
(118) Standard

Rule Violation/Tag #/Citation Level: 10A NCAC 27G .0209 Medication Requirements
(119) Standard

Rule Violation/Tag #/Citation Level: 10A NCAC 27G .0209 Medication Requirements
(123) Standard

Rule Violation/Tag #/Citation Level: 10A NCAC 27G .0303 Location and Exterior
Requirements (736) Standard

lS AK

Client & Staff Identifier List
(Indicate staff title or number beside each name)

Client #1
Client #2
Client #3

Staff #1
Staff #2

QR

CITATION LEVEL: Number of days from survey exit for citation correction

Standard = 60 days Recite — standard = 30 days Type A = 23 days Type B = 45 days
Uncorrected Type A or Type B Imposed = provider should provide written notification of intended
correction date

inspection_type: MHLCS Annual and Follow-up

document_type: Plan of Correction


summary: Plan of Correction - MHLCS Annual

raw_content:
2023-01-19 17:15

Division of Health Service Raguietion

Lal RUSUPPLIER REPRESENTATIVE'S SIGNATURE
BS6OP __O

ST

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHLO44-006

1 1 >> P 3/13

PRINTED: 01/09/2023
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (63) DATE SURVEY
A BUILDING: COMPLETED

B. WING 04/05/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE

BURKWELL

3476 MORGANTON BOULEVARD

LENOIR, NC 28645

SUMMARY STATEMENT OF DEFICIENCIES

(BACH DEFICIENCY MUST 3E PRECEDED BY FULL,
REGU STARY NR (SC INENTICVING INEARMATION

INTIAL COMMENTS

An annual survey was completed on January 5,
2023. Deficiencies were cited.

This faciity Is licensed for the following service
category: 10A NCAC 276 .1700 Residential

Troatmont Sta Scours for Chiteron oF

Adolescents.

This facility Is licensed for 8 and currently had a

of audits of 3 current cllents and 1 former alent.

V 387} 27G .0604 Incident Reporting Requirements

1OANCAC 276 604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all

the provision of billable services or while the

incidents and faved 1] deaths inveiving tha eliants

90 days prior to the incidant te the LME
responsible for the catchment area where
services are provided within 72 hours of

be submitted on a form provided by the

in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) raporting provider contact and
identification information;

(2) olient identification Information;

(3) type of incident;

(4) description of incident:

(6) status of the effort to determine the
cause of the Incident: and

cansus of 7 cilents, The survey sample consisted

level II Incidents, except deaths, that occur during
consumer is on the providers premises or level Ill

to whom the provider rendered any service within

becoming aware of tha Incident. The report shall

Secratarv. The report mav be submitted via mail.

PROVIDER'S PLAN OF CORRECTION
(GACH CORRECTIVE ACTION SHOULD BE
CROSS. REFERENCED Th) THE APPROPRIATE
DEFICIENCY)

V 367

TITLE (8) DATE:

merase Lael or, VHP/LOL3

“ KBa01 Ireontinuation shant 4 of 4

2023-01-19 17:16 1 1 >> P 4/13

PRINTEO: 01/09/2023
FORM APPROVED
Division of Health Service Requiation

‘STATEMENT OF DEFICIENGIES (1) PROVIDERUSUPPLIER/CLIA (2) MULTIPLE CONSTRUGTION (43) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFIGATION NUMBER; A BULDING: COMPLETED

MHL014-008 B.WING 4/05/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3478 MORGANTON BOULEVARD
LENOIR, NC 28645

Xa) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (GAGH DEFICIENCY MUST BE PRESEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
wG REGULATORY OR LSC IRENTIFYING INFORMATION) TR Te RE ERE RCIENCY) APPROPRIATE,
HEN

BURKWELL

Continued From page 1

(8) other Individuals or authorities notified
or responding,

(b) Category A and 8 providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report reciplents by the and of the next business
day whenever:

(1) the provider has reason to beliave that
Information provided In the report may be
erroneous, misiaading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavallabla.

(c) Category A and B providers shall submit,
upen request by the LME, other information
obtained regarding the incident, Including:

(1) hospital recards including confidential
information;

{2) reports by other authorities; and

(3) tha provider's response to the incident.
(d) Category A and 8 providers shall send 8 copy
of all lavel II incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
Providers shall sand a copy of ail level Ili
incidents involving & cllant death fo the Division of
Health Service Regulation within 72 hours of
becoming aware of tha incidant. In cases of
client death within seven days of use of sequsion
or restraint, the provider shall report the death
immadiately, as required by 1(0A NGAC 260
.0300 and 10A NCAC 27E .0104(8)(18).

(e) Category A and & providers shall send a
teport quarterly to the LME responsible for the
catchment area where services are provided.
The report shall ba submitted on a form provided
by the Secratary via electronic means and shall
include summary information as follows:

Division of Health Service Regulation
STATE FORM ca KB8017 Ifeontinuntion sheat 2ol 4

2023-01-19 17:16 11 >> P 5/13

PRINTED: 01/09/2023
FORM APPROVED
Divisian of Health Service Regulation
STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA (42) MULTIPLE CONSTRUGTION (43) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED

MHL014.006 8, WING, 01/05/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

SUMMARY STATEMENT OF DEFICIGNCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENCED TO ane APPROPRIATE
DEFICIENCY)

BURKWELL

Continued From page 2

(1) madication errors that do not meet the
definition of a level If or level Il Incident;

(2) restrictive Interventions that do net mest
the definition of a level Il or level Hi Incident:

{3) searches of a client or his living ares;
(4) seizures of client property or property in
the possession of a client;

(8) the total number of level {| and level Il
inckents that occurred; and

(6) _ a statement Indicating that there have q , | Director
been no reportable incidents whenever no Toomonatos Ye Directo
incidents have occurred during the quarter that Projected Completion Date: 3/6/2023

meet any of the criteria as sat forth In Paragraphs
{a) and (4) of this Rule and Subparagraphs (1) Mandatory trainings are being put In place
through (4) of this Paragraph. for all rasidential staff. The training that Is
oceurring for the Burkwell facation will be
held on January 1Bth, 2023. This training
encompasses level 1 and level 2/3
requiraments per company and DHSR
standards. Timelines and requirements
will be discussed in depth with examples.
to assist staff with completing these. In
order to prevent this occurrence from

This Rule is not met as evidenced by: happening again, staff are being trained
Based on record review ane Interview, the facility (also at training on the 18th) that when an
falied to report all level !I incidents In the Incident IRIS report 8 needed that they must
Response Impravement Systam (IRIS) and notify ie ne wee owes that th " mes ve

the Local Management Entity (ME) responsible completed within the 72 hour time frame
for the catchment area where services were If itis a weekend then the staff must notity
provided within 72 hours of becoming aware of the On-call who will then notify the Qt

the incident affecting 1 of 1 audited Former Client director via emall immediately, Staffs have
(FC #4), The findings are; been provided with a IRIS report farm to

. send to the QI director as well so that the
Review on 1/5/23 of FO #4’s racord revealed: director may fill out the IRIS thoroughly.

Admitted 11/18/22, | The QI directar will monitor the need for
~Discharged 12/17/22. i; anJRIS completion dally via a specialized
Diagnoses of Disruptive Mood Dysregulation email, Ql@focusbhs.com, to ensure that
Disorder, Attention-Deficit Hyperactivity Disorder all IRIS raports are completed when they
and Other Specified Trauma and Stressor oeeur,

Related Disorder,
Oivision of Health Service Regulation
STATE FORM a8 KBaO1 (t continuntion aheol Sat 4

2023-01-19 17:16 1 1 >> P 6/13

PRINTED: 01/09/2023
FORM APPROVED
of Health Service Ra
STATEMENT OF DEFICIENCIES {X%2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AN® PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED

MHL014-006 WING ete 04/05/2023

NAME OF PROVIDER OR SUPPLIER STRERT ADDRESS, CITY, STATE, ZIP CODE.
3476 MORGANTON BOULEVARD
LENOIR, NC 26645

SUMMARY STATEMENT OF DEFIGIENGIES. PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST 8& PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR 1.56 IDENTIFYING INFORMATION) acacia oN oy PROPRIATE

FICIENCY:

BURKWELL,

Continued From page 3

+12/17/22 shift nate fram 9:00 a.m. to 2:00 p.m. «
"Client is in hospital for self harming and property
destructive behaviors.”

Review on 1/6/23 of factlity level ft and level iit
incidents submitted in IRIS revealed:
“No incident report for 12/17/22 regarding FC #4,

Intarview and record review ort 1/5/23 with the
Quality Improvement/Residential Treatment
Director revealed:

~She had a more detailed shift note regarding the
incident with FC #4 and pictures of the property
damage,

~The plotures revealed holes In the wall and Jarge
chunks of drywall lying on tha floor as a regult of
FC #4's behavior.

-The detallad shift note indicated the local police
were called and FC #4 was transported to the
hospital,

~The staff on call at the time af the incident was
responsinle to do an IRIS report.

-She would complete the IRIS report today and
diseuss with staff who did nat complete the
report,

Olvigion of Health Servica Regulation
STATE FORM sa REGO Weortinuation shoot 4.of 4

2023-01-19 17:15 1 1 >> P 2/13

“BEHAVIORAL HEALTH SERVICES, LC

PO Box 3624 Morganton, NC 28680

January 19, 2023
Attention: Mental Health Licensure and Certification Section-NC Division of Health Service Regulation
Re: Statement of Deficiencies and Plan of Correction

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center, Raleigh, NC 27699-2718

Re; Annual Survey completed January 5/6, 2023
Burkwell, 3476 Morganton Boulevard, Lenoir, NC, 28645
MHL #014-006

The Landing, 2419 Morganton Boulevard, Lenoir, NC, 28645
MHL #014-087

E-mail Address;

Dear NCDHHS Survey Team,
Attached are the plans of corrections for The Landing and Burkweil locations for Focus Behavioral Health
Services, | hope you will find these corrections to your standards, Thank you for your time and attention to

this matter. if you have any questions please do not hesitate to reach out to me at
orat

BSOP 1/19/1023

rector

inspection_type: MHLCS Annual


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 01/09/2023

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
A. BUILDING: COMPLETED
01/05/2023

MHL014-006

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual survey was completed on January 5,
2023. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 8 and currently had a
census of 7 clients. The survey sample consisted
of audits of 3 current clients and 1 former client.
V 367] 27G .0604 Incident Reporting Requirements V 367

TITLE

6808 KB8011

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/09/2023

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL014-006 01/05/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 1 V 367

(6) other individuals or authorities notified
or responding.

(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.

(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.

(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.

The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 2 of 4

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 01/09/2023

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

MHL014-006

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

FORM APPROVED

) DATE SURVEY
COMPLETED

01/05/2023

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 2 V 367

(1) medication errors that do not meet the
definition of a level II or level Ill incident;

(2) restrictive interventions that do not meet
the definition of a level II or level III incident;

(3) searches of a client or his living area;
(4) seizures of client property or property in
the possession of a client;

(5) the total number of level II and level III
incidents that occurred; and

(6) a statement indicating that there have

been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to report all level II incidents in the Incident
Response Improvement System (IRIS) and notify
the Local Management Entity (LME) responsible
for the catchment area where services were
provided within 72 hours of becoming aware of
the incident affecting 1 of 1 audited Former Client
(FC #4). The findings are:

Review on 1/5/23 of FC #4's record revealed:
-Admitted 11/18/22.

-Discharged 12/17/22.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Attention-Deficit Hyperactivity Disorder
and Other Specified Trauma and Stressor
Related Disorder.

Division of Health Service Regulation
STATE FORM

6809

KB8011

If continuation sheet 3 of 4

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL014-006

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/09/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/05/2023

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 3 V 367

-12/17/22 shift note from 9:00 a.m. to 9:00 p.m. -
"Client is in hospital for self harming and property
destructive behaviors."

Review on 1/5/23 of facility level Il and level III
incidents submitted in IRIS revealed:
-No incident report for 12/17/22 regarding FC #4.

Interview and record review on 1/5/23 with the
Quality Improvement/Residential Treatment
Director revealed:

-She had a more detailed shift note regarding the
incident with FC #4 and pictures of the property
damage.

-The pictures revealed holes in the wall and large
chunks of drywall lying on the floor as a result of
FC #4's behavior.

-The detailed shift note indicated the local police
were called and FC #4 was transported to the
hospital.

-The staff on call at the time of the incident was
responsible to do an IRIS report.

-She would complete the IRIS report today and
discuss with staff who did not complete the
report.

Division of Health Service Regulation
STATE FORM

6809

KB8011

If continuation sheet 4 of 4

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division o

STATEMENT OF DEFICIENCIES

f Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/09/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL014-006 B. WING 04/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on April 8,
2020. The complaint was unsubstantiated (intake
#NC 00163302). No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
Division of Health Service Regulation
TITLE (X6) DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

6899

RXOP11

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 03/02/2020

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL014-006 — 02/28/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on February 28,
2020. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6609 MROB11 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL014-006

BURKWELL

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD
LENOIR, NC 28645

PRINTED: 09/16/2019

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 09/11/2019

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

INITIAL COMMENTS

A Follow up survey for a Type A1 was completed
on 9/11/19. The following deficiencies were
reviewed and are now back in compliance. No
other deficiencies were cited.

-10A NCAC 27G. 1701 Scope (V293) Type A1,
-10A NCAC 27G .0201 Governing Body Policies
(V105) crossed referenced,

-10A NCAC 27G .0203 Competencies of
Qualified Professionals and Associate
Professionals (V109) crossed referenced,

-10A NCAC 27G .0205 (a) Assessment and
Treatment/Habilitation or Service Plan (V111)
crossed referenced,

-10A NCAC 27G .0205 (c) Assessment and
Treatment/Habilitation or Service Plan (V112)
crossed referenced,

-10A NCAC 27G .1705 Requirements for
Licensed Professional (V297) crossed
referenced.

This facility is licensed for the following service
category:

10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children or Adolescents.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

V 000

6899

TITLE (X6) DATE

9Q8011 If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up