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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES SUPPLIERICLI

AND

(x1) PROVIDER/
IDENTIFICATION NUMBER

MHL013-240

pa
NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

(x4) 10 | SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST 8£ PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

|
V 000!
| INITIAL COMMENTS

Acomplaint and follow-up survey was completed
| on 6/6/25. The complaint was unsubstantiated

| (intake #NC00230200). Deficiencies were cited.

|

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

This facility is licensed for 6 and has a current
census of 4. The survey sample consisted of
audits of 4 current clients, 3 former clients.

V 132, G.S. 131E-256(G) HCPR-Notification,
Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shal! ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to

| any act listed in subdivision (a)(1) of this section
(which includes:

ja. Neglect or abuse of a resident ina

| healthcare facility or a person to whom home care
services as defined by G.S. 131E-136 or hospice
services as defined by G.S. 131E-201 are being
provided.

b. Misappropriation of the property of a
resident in a health care facility, as defined in
subsection (b) of this section including places
where home care services as defined by G.S.
131E-136 or hospice services as defined by G.S.
131E-201 are being provided.

C. Misappropriation of the property of a
healthcare facitity.

\d. Diversion of drugs belonging to a health
care facility or to a patient or client.

| e€ Fraud against a health care facility or

| against |
SEU EEE EEE CA ee

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

CONCORD, NC 28027

PREFIX

iD
TAG

V 132 |

PRINTED: 06/18/2025
FORM APPROVED

_Steven Lanham

(X3) DATE SURVEY
COMPLETED

R-C
06/06/2025

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

‘|
DEFICIENCY)

RECEIVED |
JUN 30 2025

DHSR-MH Licensure Sect

x5)
COMPLETE
DATE

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

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

STATE FORM 5800 QEHS11 {f continuation sheet_1 of 27
eee. EST if continuation sheet_1 of 27_

STATEMENT (41) (X2) MULTIPLE CONSTRUCTION (X3) DATE
OF PROVIDER/SUPPLIER/CLIA, SURVEY
DEFICIENCIES | IDENTIFICATION NUMBER: } ®- BUILDING
AND PLAN OF COMPLETED
CORRECTION
R-C
MHL013-240 8. WING 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4)10 | SUMMARY STATEMENT OF 1D PROVIDER'S PLAN OF CORRECTION | as)
PREFIX DEFICIENCIES PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG | (EACH DEFICIENCY musT TAG | CROSS-REFERENCED TO THE APPROPRIATE | OATE
BE PRECEDED BY FULL | DEFICIENCY)
REGULATORY OR LSC
[IDENTIFYING INFORMATION)
Division of Health Service Regulation
6809 OEHS11 If continuation sheet 2 of 31

STATE FORM

Division of Health Service Regulation

PRINTED: 06/18/2025

|
V 132| Continued From page 1

a patient or client for
whom the employee
is providing services).
Facilities must
have evidence
that all alleged
| acts are
investigated and
must make every
effort to protect
residents from
harm while the
investigation is in
progress. The
results of all
investigations
must be reported
fo the
Department within five
working days of the
initial notification to the
| Department.

This Rule is not met
| as evidenced by:
Based on record
review and
interview, the
facility failed to
ensure that the
North Carolina
Health Care
Personnel
Registry (HCPR)
was notified of all
allegations against
health care
personnel within
24 hours, failed to
make every effort
to protect clients
from harm while
an investigation
was in progress,
and failed to
report the results
of the
investigation
within five working
| days of the initial
| notification. The
findings are

Review on 5/22/25 of
“Notification of CPS
(Child Protective

Division of Health Service Regulation

Vv
132

FORM APPROVED
* Measures put in place to correct the deficient area of practice (i.e. changes in policy and Completed
procedure, staff training, changes in staffing patterns, etc.). 06/12/2025
+ Measures will be put in place to prevent the problem from occurring again. and Quarterly
Ongoing

General Staff Meeting Report: 06-12-2025
Staff mtg was completed on 06/12/2025 to review DHSR findings and recommendations.
Information included the following

¥ Professional Development, Refresher & Upcoming Training(s)

Incident Report Training:
https //drive.google com/file/d/1Y¥ O9aJMaSHTV1HAgt4M9PTmSMr2zEZWG7/view?usp=drive link

NC Healthcare Registry Policy:
| https ://drive google com/file/d/1cindRLagNvdcu3HGZxY Gil6TxyjaM4az/view?usp=sharing

Complaint Intake is available to receive complaints regarding the care and services provided to
patients/residents/consumers by health care facilities/agencies/homes licensed by the Division of
Health Service Regulation.

e Health Care Personnel Investigations reviews and investigates allegations of abuse,
neglect, fraud, diversion of drugs, and misappropriation of property against unlicensed
health care workers and lists any substantiated finding(s) on the Nurse Aide ! Registry
and Health Care Personnel Registry for use by health care providers in their hiring
process

Client Rights:
https ://drive google com/file/d/1667rD69uHc8UQacse2S 10GKrpdGfengS/view?usp=drive_link

=

The agency will continue to follow the protocol for all allegations of abuse, neglect, fraud,
diversion of drugs, and misappropriation of property against unlicensed health care workers

“Please Note”

TH did not fail to protect clients from harm while an investigation was in progress.

Investigating personnel stated there was no need to remove employee from contact of alleged victim due to
victim already being discharged from the facility at the time to notification.

+ Who will monitor the situation to ensure it will not occur again: Owner/. Director
+ How often the monitoring will take place: Quarterly

ba OFHS5114 If continuation sheet 3 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

| Services) Involvement"
dated 4/1/25 revealed:

| -". Allegedly, the

| female group
home staff
member (Staff #4)
kissed the 17-year-
old child (Former
Client (FC) #1) on
her lips. Female
staff (#4) went into
the child's (FC #1)
room, turned off
the lights and
undressed and
attempted to touch
her, child pushed
away..."

Review on 5/27/25 of
FC #1's record
revealed:
-Age 17.
-Admitted 10/24/24.
-Diagnoses: Major
Depressive Disorder,
Mild Intellectual
Disabilities ,
Oppositional Defiant
Disorder.
-Discharged 3/27/25.
-Discharge Summary:
| "Discharge
| Disposition-Since her
(FC #1) arrival

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFICAT!
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING: COMPLETED

R-C
MHLO013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION | Co)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | SOMPLSTE

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

DEFICIENCY)

Division of Health Service Regulation
STATE FORM eee OEH511 If continuation sheet 4 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

v 122) Continued From page 2

| (10/24/24), [FC #1] has exhibited extreme
behaviors on a daily basis to include sexual
inappropriateness with peers (other clients), staff,
teachers, and school administrators,

| manipulation, staff splitting, compulsive lying,
false claims of sexual assault, property
destruction, aggression, profanity,
noncompliance, multiple AWOL (absent without
leave) attempts, physical assaults, verbal abuse,
spitting, staff intimidation, etc

To ensure safety for both [FC #1] and others

| (staff and clients) in the home (facility), the
Resident (FC #1) was discharged from the facility
because the resident was physically and verbally
aggressive, displayed property destruction,
attempted to go awol, and made multiple self-
harm attempts and threats."

-Course of Treatment ...Since admission
(10/24/24) to level three services, the resident
has shown constant regression to include
instances of property destruction, verbal and

| physical aggression, attention-seeking behaviors,
false allegation of sexual assault [van driver,
school officials, residential staff (facility staff),
AWOL attempts, suicidal ideations, and self-harm
attempts resulting in multiple hospitalizations ...”

Review on 5/22/25 and 6/6/25 of the North
Carolina Incident Response Improvement System
(IRIS) from 1/1/25-6/6/25 revealed:

| -No documentation in IRIS and no report to HCPR
of FC #1's 4/1/25 allegation of Staff #4 kissing and
attempting to touch FC #1.

-No documentation of FC #1's allegation of abuse
by “van driver, school officials, residential staff
(facility staff)" as described in the discharge
summary dated 3/27/25.

Interview on 5/28/25 with Department of Social
Services (DSS) Investigator revealed:

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLIA] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING
RC

MHL013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(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 OATE

DEFICIENCY)

Division of Health Service Regulation
STATE FORM ease OEH511 if continuation sheet § of 31

PRINTED: 06/18/2025
FORM APPROVED
Division of Health Service Regulation

v132) via2 |
| Continued From page 3 |

-FC#1 had a history making allegations of abuse |
| that had been investigated by DSS in the past |
| year.

-FC #1 had already been discharged from the
facility on 3/27/25 and moved to another facility
placement.

-FC #1's information about the 4/1/25 allegation
of Staff #4 kissing and attempting to touch FC #1,
“didn't corroborate with what anyone else (staff,
clients) was saying."

-He interviewed facility staff, current clients, FC |
#1 and FC #1's DSS Social Worker/Legal | |
Guardian (SWILG) and concluded, based on FC |

#1 report and reports from staff and clients in the
facility, that there was a lack of evidence to |
substantiate the report of abuse. |

| Interview on 6/2/25 with FC #1 revealed:

| -She had been at the facility for about 2 years and | |
liked it there. |
Did not have any concerns with staff. | |
-Had been in the hospital (psychiatric) since her
IVC and discharge from the facility on 3/27/25. -

| “Just want to say | was obsess (obsessed). | like

her (Staff #4) alot. | did appreciate her, had love

| for her in a sense; my love for her is gone; not, |

| mean, not all the way. | regret what | did and said; |
| was weird toward her, called her a b****h, | really

| regret that; wasn't weird, but I was clingy; | got |

attached too fast." |

-Staff #4 had touched her on the chest and tried
to kiss her once when she and Staff #4 were
alone in the facility (date unknown).

-Was touched by Staff #4 a week before she was
discharged on 3/27/25, when she and Staff #4
had fallen asleep on the couch together and were
caught by the HM/QP#2, "they [HM/QP#2] were

walking in (facility)...and they (HM/QP#2) said ‘get

| up’ and she (Staff #4) said ‘no, lay back down’,

[and | was confused about who | should listen to; |

‘STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED

A. BUILDING
RC

MHLO13-240 06/06/2025

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

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | 5)
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 OATE

DEFICIENCY)

Division of Health Service Regulation
STATE FORM ad OEHS11 if continuation sheet 6 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025

FORM APPROVED

Vv 132) 7

| Continued From page 4

| took [Staff #4]'s side because | care about her
more. | feel like [HM/QP#2] knew (about the
touching)...she (HM/QP#2) thought | was in love
with her (Staff #4)."
-Was scared to tell anyone because she didn't
think she would be believed.

Interview on 6/3/25 with client #4 revealed:

-FC #1 had left the facility often, police had to go

| get her, and was not gone more than 30 minutes. -
| FC #1 liked lying about Staff #4 and would get

| angry with Staff #4 when she didn't give FC#1 the
attention FC #1 wanted

| -Staff #4 never acted in a sexual manner toward
FC #1 and was never inappropriate.

-FC #1 had lied on the van driver and alleged he
had touched her.

-FC #1 had a crush on the Former QP (FQP) and
would ask facility staff to call the FOP.

| -FC #1 made sexually inappropriate comments
about what she would do to Staff #4 and had
made similar comments about girls at school.

Attempted interview on 6/2/25 contact with FC
#1's DSS SWILG left voice message with
contact information for follow up and there was
no contact from DSS SW/LG. There was no
return call prior to survey exit.

Attempt interview on 6/4/25 with Former Qualified
Professional (FQP) was unsuccessful, left voice
message with contact information for follow up
and there was no contact. There was no return
call prior to survey exit.

Interview on 6/3/25 with Staff #2 revealed: -
| “[Staff #4] was always making sure [FC #1] was
| going in the right direction; she (Staff #4) was
good with handling [FC #1] ‘ s behaviors. -FC
#1 had a history of lying and facility staff

V 132

(%1) PROVIDER/SUPPLIERICLIA
(DENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION A

MHL013-240

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

COMPLETED

BUILDING:

R-C

06/06/2025

STREET ADDRESS. CITY. STATE. ZIP CODE.

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

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

(4) 1D
PREFIX
TAG

|
|
|

Division of Heaith Service Regulation

STATE FORM 6809

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

OEHS11

(x5)
COMPLETE
DATE

if continuation sheet 7 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

T
V 132 | Vv 132

Continued From page 5

would only interact with FC #1 within sight of the
facility cameras or they would only address her |
from the doorway of FC #1's bedroom without |
| entering.

-lf FC #1 liked someone, "she (FC #1) would

| always try to take things further, like asking staff
out and when she doesn't 't get an answer she
will lie... she (FC #1) doesn't ' t like rejection and

| would make things up."

| -Had never observed anything sexual between
Staff #4 and FC #1

| -FC #1 liked hugging and staff was helping FC #1
to work on respecting personal space. "We | |
(staff) just dapped (fist bump) her up instead of |

hugging" because of how long FC #1 would try to
| extend a hug.

-Did not know about IRIS and HCPR or who
would be responsible for reporting.

| Interview on 6/3/25 with Staff #3 revealed: |
-FC #1 had made “multiple allegations".

-If FC #1 got mad or had a crush on someone or
was not getting her way, she would say someone |
sexually assaulted her, hit her and she had made
an allegation of assault with client #4's van driver. - |
Staff was constantly redirecting FC #1 about
personal space.

-FC #1 liked hugging and staff would give high
fives instead of hugging.

--Did not know about IRIS and HCPR, but thought |
QPs or HR/CC were responsible.

| Interview on 6/4/25 with Staff #4 revealed:

-Was named as the perpetrator of abuse by FC
#1 and was made aware of FC #1's allegation of |
| abuse (kissing and attempted touching) when the |
4/1/25 report came from DSS and the DSS Social |
| Worker Investigator arrived at the facility in April | \
2025 (dates unknown).
-Had never had any intimate or inappropriate |

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (x2) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AC BUILDING: COMPLETED

R-C

MHLO13-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

ayo | SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
Ta | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Division of Health Service Regulation
STATE FORM = OEHS511 If continuation sheet 8 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

Wits2 Continued From page 6 VRB |

contact with FC #1.

-"I'm not sure if they (facility) contacted or made

any reports to anything (IRIS, HCPR)."

-"The facility did an investigation (April 2025). |

Once it (FC #1's 4/1/25 allegation of Staff #4 |

| kissing and attempting to touch her) was brought |

up, it was discussed. [Home Manager |
|

| (HM/QP#2)] and | were contacted by [Human

| Resource/Compliance Consultant (HR/CC)] and
we discussed house rules, but | don't know what
transpired outside of myself, like with other staff | |
members, | can only speak about what happened
| with me."

-QPs and HR/CC were responsible for IRIS and
HCPR reporting

-"l was still able to work with TH (Transcending
Heights) with no breaks in employment." -
"[HR/CC] would be responsible for making reports
and doing the investigation."

Interview on 6/2/25 with the HM/QP#2 revealed:
-Provided supervision to staff.

-She and QP#1 were responsible for incident |
reporting. |
-Was aware of FC #1's 4/1/25 allegation of Staff |
#4 kissing and attempting to touch FC #1 and |
was made aware by DSS on 4/1/25

| “she (FC #1) stated that staff (#4) tried to |
sexually assault her, she didn't like it (assault) |
and she never told anyone, and that’s what DSS |
told me..."

-Was not aware of anything intimate or
inappropriate going on between FC #1 and Staff
#4 and had never observed Staff #4 conduct
herself inappropriately with clients.

-There was never a time when FC #1 and Staff
#4 would have been in the facility alone.

-No staff in the facility entered clients' rooms
and staff never shut clients' bedroom doors. - |

Staff had redirected and had addressed in | |

(x3) DATE SURVEY
COMPLETED

(x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

A. BUILDING:

R-C
06/06/2025

MHL013-240

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE | ‘COMPLETE
TAG | CROSS-REFERENCED TO THE APPROPRIATE One

DEFICIENCY)

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

Division of Health Service Regulation
STATE FORM on OEH511 If continuation sheet 9 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED.

V 132 |
| Continued From page 7

treatment team meetings that FC #1 had issues
respecting boundaries, behavior, profanity and
inappropriate comments to staff like, ‘hey, you're cute.’
-Was aware of FC #1's accusation of sexual
| assault by van driver that resulted in loss of
transportation resource.
-Had not made an HCPR report and was not
| aware if there had been an HCPR report made to
address FC #1's 4/1/25 allegation of Staff #4
kissing and attempting to touch FC #1.
-There was no facility investigation and Staff #4
was not removed from the schedule because FC
#1 had been discharged.
-QP #1 was responsible for HCPR reporting and
HRICC was responsible for internal investigation.

Interview on 6/2/25 and 6/4/25 with the QP#1
revealed:

-Was hired 3/15/25,

-Was responsible for completing IRIS reports and
HCPR reports.

-Knew that allegations of abuse were required to
be reported to the HCPR within 24 hours.
-"Investigation (date unknown) was done and she
(Staff #4) was taken off the schedule until
[HR/CC] finished her investigation. | know she
(Staff #4) was able to come back once FC #1
was gone from the facility (discharged).”

-"| wasn't there when it (Staff #4 allegedly

| kissing and attempting to touch FC #1)
happened." -Was aware that FC #1 had accused
(date unknown) the van driver of touching her
and the facility lost their use of transportation
resource, "...we (staff) talked to her (FC #1)
about lying on people when she gets angry."
-Was not responsible for the HCPR report
because FC #1 had already been discharged
from the facility on 3/27/25.

-Did not submit report to HCPR once she was

Vv 132

STATEMENT OF DEFICIENCIES 1)
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL013-240

PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION

A. BUILDING:

(<3) DATE SURVEY
COMPLETED

R-C
06/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE. ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

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

Division of Health Service Regulation
STATE FORM

sete OEH5S11

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE | COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE | DATE
DEFICIENCY) |

If continuation sheet 10 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

vitae Continued From page 8 vise

made aware sometime during the week of
3/31/25 to 4/4/25 (exact date unknown) of FC
#1's 4/1/25 allegation of Staff #4 kissing and |
| attempting to touch FC #1
-Was not sure whether there was a report to
| HCPR to address FC #1's allegation of Staff #4
kissing and attempting to touch FC #1.

Interview on 6/4/25 and 6/6/25 the HR/CC |
revealed: |
-Contracted consultant.

| -Was made aware (April 2025) by DSS SW

| Investigator of the 4/1/25 report of FC #1's
allegation of Staff #4 kissing and attempting to
touch FC #1.

-Was aware of FC #1's difficulty with boundaries,
dishonesty and history of making false
accusations of abuse

| -Did not submit report in IRIS and did not make
an HCPR report.

-The QP#1 was responsible for IRIS and HCPR
reporting.

-She was responsible to make sure the facility
followed through and completed IRIS and HCPR
reports.

-No IRIS and HCPR reports were made
because the facility only learned of the DSS
report in April 2025 and FC #1 had already been
discharged and was no longer a client in the
facility -Staff #4 was not removed from the |
facility schedule pending an investigation. | |
-Was responsible for internal investigation of any
| allegations.

-"| did not do an internal investigation. | did do an | |
interview with [Staff #4], but did not do an internal
investigation because DSS was already doing the
investigation. | talked with [Staff #4] and got her
statement."

| This deficiency constitutes a re-cited deficiency

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING:

COMPLETED

R-C
06/06/2025

MHL013-240
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | 0%)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE BSE

| DEFICIENCY)

Division of Health Service Regulation
STATE FORM ba OEH511 If continuation sheet 11 of 31

PRINTED: 06/18/2025

Division of Health Service Regulation

FORM APPROVED

V 132 V 132
Continued From page 9 and must be
corrected within 30 days.

v 366, 27G .0603 Incident Response Requirements V 366 |

| |
| 10A NCAC 27G .0603 INCIDENT |
RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS |
(a) Category A and B providers shall develop and
implement written policies governing their
response fo level |, II or Ill incidents. The policies
shall require the provider to respond by:
(1) attending to the health and safety needs
of individuats involved in the incident:
| (2) determining the cause of the incident;(3)
developing and implementing corrective measures
according to provider specified timeframes not to
exceed 45 days;
(4) developing and implementing
measures to prevent similar incidents according
to provider specified timeframes not to exceed
45 days; (5) assigning person(s) to be
| responsible for implementation of the corrections

and preventive measures;

(6) adhering to confidentiality requirements
| set forth in G.S. 75, Article 2A, 10A NCAC 26B, |
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and
(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
| (b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the
federal regulations in 42 CFR Part 483 Subpart |
(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall |
develop and implement written policies |
governing their response to a level Ill incident
| that occurs while the provider is delivering a
| billable service

STATEMENT OF DEFICIENCIES xa) PROVIDER/SUPPLIERICLIA | 02) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFICATI R:
AND PLAN OF CORRECTION ICATION NUMBEI A. BUILDING.

MHL013-240
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

| SUMMARY STATEMENT OF DEFICIENCIES 1D | PROVIDER'S PLAN OF CORRECTION

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(4) 1D
PREFIX
TAG

Division of Health Service Regulation

STATE FORM $09 OEH511

COMPLETED

R-C
06/06/2025

(x5)
COMPLETE
DATE

If continuation sheet 12 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

V 366) Continued From page 10 V 366

or while the client is on the provider's premises.
The policies shall require the provider to respond |
by: |
(1) immediately securing the client record |
by:

(A) obtaining the client record; |
(B) making a photocopy; |
(C) certifying the copy's completeness; and (D)
transferring the copy to an internal review team;

(2) convening a meeting of an internal |
review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete ail of the activities as
follows: |
(A) review the copy of the client record to
| determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

| (B) gather other information needed;

(C) issue written preliminary findings of fact |
within five working days of the incident. The |
preliminary findings of fact shall be sent to the |
LME in whose catchment area the provider is |
located and to the LME where the client resides, if | |
different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for

(Xa) DATE
SURVEY

(X2) MULTIPLE CONSTRUCTION
A BUILDING

STATEMENT (x1)
PROVIDER/SUPPLIERICLIA

IDENTIFICATION NUMBER

DEFICIENCIES
AND PLAN OF
CORRECTION

COMPLETED

R-C
06/06/202

MHL013-240

STREET ADDRESS, CITY, STATE. ZIP CODE

550 ARCHDALE DRIVE

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

Division of Health Service Regulation
STATE FORM oe OEHS11 if continuation sheet 13 of 31

Division of Health Service Regulation

4) 1D
PREFIX
TAG

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

Continued From page 11

minimizing the
occurrence of future
incidents. If all
documents needed

for the report are not
available within three
months of the

incident, the LME

may give the

provider an

extension of up to
three months to

submit the final

report; and

(3)

immediately

notifying the

following: (A)

the LME

responsible for the
catchment area

where the services

are provided

pursuant to

Rule .0604;

(B) the LME where
the client resides, if
different;

(C) the provider
agency with responsibility
for maintaining and
updating the client's
treatment plan, if different
from the reporting
provider;

(D) the Department;
(E) the client's legal
guardian, as applicable;
and

(F) any other
authorities required by
law.

This Rule is
not met as

Division of Health Service Regulation
STATE FORM

PRINTED: 06/18/2025

FORM APPROVED
i PROVIDER'S PLAN OF CORRECTION x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
i} DEFICIENCY)
Completed

+ Measures put in place to correct the deficient area of practice (i.e. changes in policy and 93/23/2025.
procedure, staff training, changes in staffing patterns, etc.). melee an
+ Measures will be put in place to prevent the problem from occurring again. oigaing.

TH will provide “refresher” training to all current residential staff and provide new hire
training to ensure all staff are familiar and knowledgeable of the incident response
| protocols.

[See Below]

incident Reporting-Level 1

Policy
Transcending Heights LLC requires employees to document all Level | incidents and have documentation
available onsite for regular reviews. Level | incidents are NOT to be entered into the IRIS web-based reporting

system.

Procedures

The Incident Intake Information Farm is the format that is “acceptable to TRANSCENDING HEIGHTS LLC."
and is to be used to report all Level 1 incidents.

ALevel 1 incident is any occurrence that is not consistent with the routine operation of the facility or service or
the routine care of a resident and that is likely to lead to adverse effects upon a resident and does not meet the
definition of a Level 2 or 3 incidents. For further explanation, please refer to the DHHS

Incident and Death Response System Manual developed by DMH available at
http: /Avww.nedhhs.gov/mhddsas/statspublications/Manuals/incidentmanual2-25-11 pdf
Acopy of which also may be found in the facility office

Level | incidents include:
1. Restrictive Interventions:
| Any planned use of a restrictive intervention administered appropriately and without discomfort, compliant or

injury.

“TH Practices Physical Restraints as a LAST RESORT within its facilities and attempts LEAST RESTRICTIVE
| MEASURES BEFORE THE USE OF RESTRAINTS OR POLICE INTERVENTION.

2. Medication Errors |
‘Any error that a physician or pharmacist has determined does not threaten the resident's health or safety.
Providers of periodic services should report an error for resident's who self-administer medications as soon as.
learning of the incident |
Wong Dosage Administered

Wrong Medication Administered

Wrong Administrative Technique

Wrong Time (over 1 hour from prescribed time)

Wrong Person Given Medication

Missed Dose of Prescribed Medication

Refused Dose of Prescribed Medication

Dose Preparation Error

Loss or Spillage of Medication

Other Medication Errors

~ ose span ee

3. Other Incidents
Any search of resident's living area or seizure of resident's property. (“This does not include routine “Consent
Searches” as described in the agency policy. |

TH requests that all Incident Intake Information Forms be filed with the agency office by completing the form
and submitting it within 24hrs to the Program Director. The Incident Intake Information Form is available in the
agency office file cabinet. These forms are to be kept in each resident's record at the agency and be available
for review by surveyors if requested,

Reminder:
You MUST contact the Facility Director, HS Manager, and Clinical QP via text/email regarding an incident that
results in injury or medical/psychiatric hospitalization immediately.

Staff were provided with instruction and training as evidenced below in the staff memo dated March 23, 2025

esce OEHS11 if continuation sheet 14 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

evidenced by:
Based on | ec

record reviews | | | } I | | O
and interviews, |

the facility March 23, 2025
failed to
implement
written policies
governing their ‘ONLINE tei pert: The Document is completed ontine
response to a
level |, and Ill Wann OlgazCDanEE Deana ecusne stat
incidents. The Paper Form Incident Report: The document can be printed and completed
findings are: n e-gongle com M =!

Review on 5/22/25 of ji as Plequst
“Notification of CPS (Child | 7:
Protective Services) |
Involvement" dated 4/1/25 |
revealed:

-". Allegedly, the |
female group home |
staff member (Staff |
#4) kissed the 17 year
old child (Former |
Client (FC) #1) on her |
lips. Female staff (#4) |
went into the child's |
(FC #1) room, turned
off the lights and
undressed and
attempted to touch

| General Staff Meeting Report: 06-12-2025
| Staff mtg was completed on 06/12/2025 to review DHSR findings and recommendations.
| Information included the following:

¥ Professional Development, Refresher & Upcoming Training(s)
Incident Report Training:
| https://drive.qoogle com/file/d/1¥ O9adMgSHTV 1 HAgt4M9PTm9MI2zEZWG 7/view?usp=drive link

NC Healthcare Registry Policy: {
| https //drive.google com/file/d/1cindRLagNvdcu3HGZxY Gil6TxyjaM4az/view2usp=sharing |
| Complaint Intake is available to receive complaints regarding the care and services provided to
| Patients/residents/consumers by health care facilities‘agencies/nomes licensed by the Division of
| Health Service Regulation. |
| * Health Care Personnel Investigations reviews and investigates allegations of abuse,

| neglect, fraud, diversion of drugs, and misappropriation of property against unlicensed |
Ue _____i eso oeeeweeererwm: ae sppmprrenon on propery against unlicensed

Division of Health Service Regulation
STATE FORM ad OEHS11 if continuation sheet 15 of 31

PRINTED: 06/18/2025
FORM APPROVED
Division of Health Service Regulation

health care workers and lists any substantiated finding(s) on the Nurse Aide | Registry
and Health Care Personnel Registry for use by health care providers in their hiring
process.

Client Rights.
https //drive.qoogle com/file/d/1667rD69uHc8UQacse2S 1 OGKrpdGfengS/view?usp=drive_link

+ Who will monitor the situation to ensure it will not occur again: Owner! Director
a it ike place: Quarterly

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. COMPLETED

A. BUILDING:
R-C
MHL013-240 06/06/2025

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

550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

(4) 1D | SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Division of Health Service Regulation
STATE FORM oe OEH511 \f continuation sheet 16 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation
V 366

Continued From page 12

her, child pushed away...”

Review on 5/27/25 of FC #1's record revealed:
-Age 17

-Admitted 10/24/24.

-Diagnoses: Major Depressive Disorder, Mild
Intellectual Disabilities, Oppositional Defiant
Disorder.

-Discharged 3/27/25.

| -Discharge Summary, completed 3/27/25 by

| Former Qualified Professional (FQP):

| -"Discharge Disposition-Since her (FC #1) arrival
| (10/24/24), [FC#1]} has exhibited extreme
behaviors on a daily basis to include sexual
inappropriateness with peers, staff, teachers, and
school administrators, manipulation, staff
splitting, compulsive lying, false claims of sexual
assault, property destruction, aggression,
profanity, noncompliance, multiple AWOL (absent
without leave) attempts, physical assaults, verbal
abuse, spitting, staff intimidation, etc. To ensure
safety for both [FC #1] and others in the home,
the Resident was discharged from the facility
because the resident was physically and verbally
aggressive, displayed property destruction,
attempted to go awol, and made multiple self-

| harm attempts and threats."

| -"Course of Treatment ...Since admission
(10/24/24) to level three services, the resident
has shown constant regression to include

| instances of property destruction, verbal and
physical aggression, attention-seeking behaviors,
false allegation of sexual assault [van driver,
school officials, residential staff (facility staff],
AWOL attempts, suicidal ideations, and self-harm
attempts resulting in multiple hospitalizations ..."
-"Discharge Plan-The resident was IVC'd
(involuntarily committed), and [Facility] will
support the transition to a higher level of care
and/or alternate placement."

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING. COMPLETED

R-C

MHLO013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

oD | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8)
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 bate
DEFICIENCY)

Division of Health Service Regulation
STATE FORM bid OEH511 If continuation sheet 17 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

V 366 V 366
Continued From page 13 |

| -"Discharge Outcome-Discharged-Regression.” |
|

| Review on 5/22/25 and 6/6/25 of the North |
| Carolina Incident Response Improvement System |
| (IRIS) from 1/1/25-6/6/25 revealed:
| -3/27/25 FC #1 walked away from the facility, |
| threatened self-harm, threatened harm to others |
| in the facility which and her behaviors resulted in
| call to law enforcement outcome of involuntary

| commitment

| Review on 6/5/25 of the Facility Police Calls for

| Service Report 1/1/25 through 6/5/25 revealed: - |

| 1/5/25, 16:10 (4:10pm), Domestic Assault, |

| [Former Staff #7 (FS#7)], W911, Notes: no signs |

| of suicidal ideology, group home employees are

going to work on obtaining IVC paperwork on the

juvenile (FC #1). They (facility) were advised that

we (law enforcement) are not able to transport

her (FC #1) without the IVC paperwork from the

| mags (magistrate) office; Caller is member of the

group home staff (FS #7); No Weapons; 17 YOA

| (years of age) F/M; mixed female subj (subject)

| has beat up all of the staff. has spit on the caller

(FS #7) and made threats to other reside |

(clients).” | |

| -1/24/25 13:51 (1:51pm), Child Abuse Complaint,

Self (facility), Notes: Not on scene. Intake report.

| -1/24/25, "18:46 (6:46pm), Missing Person [Staff

| #1], E911, Notes: Upon arrival | spoke with the

house manager (HM/QP#2), [HM/QP#2] who

| Stated at approximate 6:15 pm [Former Client #3

| (FC#3)] left the residence (facility)... While on site

taking notes for the 81 report [FC #3]. She |

| (FC#3) she needed to get away for the moment |

and went to [fast food restaurant]. [FC#3] stated |

| she would not leave the residence (facility) again | |
|

| and would remain in side; Arrived back home
(facility)..19:25 (7:25pm); [FC#3] WF (white |
female) blonde and bik (black) hair, blk jacket | |

STATEMENT OF DEFICIENCIES (x1), PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ALCULBING. COMPLETED

R-C
06/06/2025

MHL013-240
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES, | PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Division of Health Service Regulation
STATE FORM sen OEHS511 If continuation sheet 18 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

Vise Continued From page 14 Mia66

and furry slides, oversized jackets, walking |
| towards [local restaurant], time lapse 20mins |
| (minutes)."

-2/8/25, 15:43 (3:43pm), Missing Person Child,
[FS#8]. W911, Notes: Juvenile (FC #3)left in the
| care of para professional [Staff #9], who stated |
| she will be transporting the juvenile to [County] for
| further evaluation and placement, [FC #3]; |
| Notified 2/8/25, 15:48 (3:48pm) twrds (towards) |
| shopping center black hoodie, navy blue baby |
yoda pajama pants, [sneaker brand] shoes blk
and gry (grey) bag, and red crossbody purse left
on foot client ran away, 15 year old white female
(FC#3]." |
-3/21/25, "22:57 (10:27pm), Check Welfare, [Staff |
#6], Notes:...One female juvenile (FC #1); |
Prisoner in custody, 23:01 (11:01pm); Back at the
home (facility) but needs transport her to hospital;
| heavy set female short Mohawk hair style [FC #1] |

17 yo (year old); Female jumped out the window, |
subject have a 73 episode (mental distress).” -
3/25/25, "19:15 (7:15pm), General Disturbance | |
[QP#1], Notes: I located [FC #1] on the ramp of |
[interstate highway]. She voluntarily got in my car
and returned to the group home where | turned
her over to staff. [FC #1] state she was not going
| to hurt herself and just wanted to leave for a
while. She stated she would remain at the group
| home for the evening (19:59, 7:59pm); On
| [interstate highway]...female flagged me |
down ...walking..-caller lost sight, caller in a gray
[make/model]; history of self harm trying to walk
in between cars short haircut heavy set female |
| green shorts and purple jacket...female trying to |

run off group home no known weapons [FC #1]

17 yo female.”

4/2125, "9:45am, Child Abuse Complaint, Self,
| Notes: DSS (Department of Social Services)
report; 3/27/25 18:56 (6:56pm) Mental |
| Commitment, Notes: [FC #1]..." |

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A BUILDING:
R-C

MHLO013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(4) ID SUMMARY STATEMENT OF DEFICIENCIES 3) PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX = | (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
| DEFICIENCY)

Division of Health Service Regulation
STATE FORM oes OEHS511 If continuation sheet 19 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

v 368) Continued From page 15 Wate

| Reviews on 5/22/25 of the facility's records 2/1/25
through 5/22/25 revealed :
| -There was no documentation of level |, Il, or Ill
| incidents.
-No documentation of internal investigation. -No
documentation that the facility attended to the
health and safety needs of the individuals
involved in the incident, determined the cause of |
the incident, developed and implemented
corrective measures, developed and
implemented measures to prevent similar
incidents, and assigned person(s) to be |
responsible for implementation of the corrections
| and preventive measures. |

| Attempt interview on 6/4/25 with Former Qualified
Professional (FQP) was unsuccessful, left voice |
message with contact information for follow up
and there was no contact. There was no return |
call prior to survey exit.

Interview on 6/4/25 with Staff #4 revealed: -Was | |

made aware on 4/1/25 by DSS of the allegation

by FC #1 that Staff #4 kissed and had

attempted to touch FC #1

-Had reported escalation of client behaviors

| beginning around 3/21/25 and had reported her

concerns (March 2025) about FC #1's

inappropriate behaviors to the facility. |

| -Was not sure if facility had documented incidents |
of FC #1's behaviors. "! know what was

discussed (staff) was that she was on her 30

days (behavior contract) and her behavior on a

whole was being monitored.”

-"We (facility) keep an incident reporting log in the

| facility. | believe these things (FC #1's behaviors)

were documented."

-Had never written an incident report.

-"From my understanding, she (FQP) completed

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

R-C
06/06/2025

MHLO13-240

STREET ADDRESS, CITY. STATE, ZIP CODE
550 ARCHDALE DRIVE

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x5)

iD | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
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) |

Division of Health Service Reguiation
STATE FORM -—- OEHS511 if continuation sheet 20 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

Wis66 Continued From page 16 W886

| the incident reports...1 provided her any

| information she may need."

-Was not sure if there were any incidents
| documented. |
-Was not aware if a report was completed in IRIS |
| for FC #1's 4/1/25 allegation of Staff #4 kissing
and attempting to touch FC #1. |
-She had not been taken off the facility schedule
pending an intemal investigation.

-There had been no internal investigation
completed by the facility.

Interview on 6/2/25 with the Home
| Manager/QP#2 revealed: |
-Qualified Professional (QP). |
-She and QP #1 were responsible for reporting
incidents.

-Knew that FC #1 had issues respecting
boundaries, behavior, profanity and inappropriate
comments to staff (‘hey, you're cute’) that had
been redirected by staff and addressed in team |
| meetings. |
| -An IRIS report had been submitted for the |
3/27/25 incident resulting in FC #1 being |
| involuntarily committed.

-Was not aware if there had been a report
submitted in IRIS and HCPR for FC #1's 4/1/25
allegation of Staff #4 kissing and attempting to
touch FC #1.

-There had been no investigation and Staff #4
was not taken off shift because FC #1 had been
discharged when the facility became aware of FC
| #1's 4/1/25 allegation of Staff #4 kissing and

| attempting to touch FC #1.

Interview on 6/2/25 and 6/4/25 with the QP#1
revealed:
-Hired on 3/15/25.

| -Had been told (facility) that FC #1 had been
having a lot of behaviors and was on a 30 day

(X3) DATE SURVEY
COMPLETED

(X14) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R-C
06/06/2025

MHLO013-240

STREET ADDRESS. CITY. STATE, ZIP CODE
550 ARCHDALE DRIVE

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 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)

Division of Health Service Regulation
STATE FORM ba OFHS11 If continuation sheet 21 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025

FORM APPROVED

v366)
| Continued From page 17

contract

-"We (facility) lost our transportation because [FC
| #1] accused him (van driver) of touching her

| (March 2025) and we (staff) talked to her about

| lying on people when she gets angry. We were
able to get transportation (van) back after [FC
#1]'s discharge."

-Did not recall that the facility had internal level |
incident reports.

-"When | came she (FC #1) had just come back
from IVC because she had busted out a window
(facility)...went to hospital on 3/27 (2025), I met
her on 3/24 (2025) when she was coming back
from the hospital (IVC).

-Was responsible for completing IRIS reports. -
Did not submit incident report in IRIS and did not
report to HCPR once she was made aware of the
abuse (Staff #4 kissing and attempting to touch
FC #1) allegation, “I didn't do one (incident

| report). I'm confused why would | do an incident
report or report it ( 4/1/25 allegation) if she (FC
#1) said it (allegation) after she was discharged?"
| -"I did an incident report when the client was
\VCed (involuntarily committed) 3/27 (2025), it's in
the system, | completed it in IRIS.”

-Had not submitted any other level II or II! reports
in IRIS for behaviors as described in FC #1's
3/27/25 discharge summary.

-Did not have documentation of incident reports
to correspond with police service calls to the
facility (1/1/25 to 6/5/25).

| Interview on 6/4/25 and 6/6/25 the HR/CC
revealed:

| -Contracted consultant.

| -Responsible for overseeing reporting of

| incidents

| -Was not aware that QP#1 had not provided

| internal incidents documentation prior to survey
exit.

V 366 |

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(x1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-240

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE. ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

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

xa)10 |
PREFIX
TAG

Division of Health Service Regulation
STATE FORM

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

1D
PREFIX
TAG

OEHS11

(x3) DATE SURVEY

COMPLETED

R-C
06/06/2025

(x5)
| COMPLETE
DATE

if continuation sheet 22 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation
V 366 | V 366 |
| Continued From page 18

| -Was not aware of police reports (1/1/25 through
| 6/5/25). |
| -Was not aware if level 1, Il, Il reports were
documented for incidents of FC #1's behavior as
| described in the 3/27/25 discharge summary. .- |
Did not submit incident reports and was not
responsible for submitting IRIS reports. -Was not |
aware of the 4/1/25 report of FC #1's allegation |
of Staff #4 kissing and attempting to touch FC #1 |
| until DSS came to the facility in April 2025. | |
-The QPs were responsible for IRIS reports, “...! |
would receive a copy to keep track and make | |
sure the follow through is taken care of (IRIS and |
HCPR completed). | provide them (facility) with |
the information, then follow up to make sure it is |
done." |
| -Acknowledged she did not complete a thorough |
investigation to attend to the health and safety
needs of the individuals involved in the incident,
determine the cause of the incident, develop and
implement corrective measures, develop and
| implement measures to prevent similar incidents,
and assign person(s) to be responsible for
implementation of the corrections and preventive
measures

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days

Vv 367
| 27G .0604 Incident Reporting Requirements

| 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 Il!

i

STATEMENT OF DEFICIENCIES 04) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A BUILDING
R-C

MHLO013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES. PROVIDER'S PLAN OF CORRECTION xs)

COMPLETE

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE pele

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

Division of Health Service Regulation
STATE FORM sme OEHS511 If continuation sheet 23 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

V 367| Continued From page 19

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 shail
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:
| (A) 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

(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

V 367

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

{K1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-240

NAME OF PROVIDER OR SUPPLIER STREET ADDI

A. BUILDING:

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

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

(X4) ID
PREFIX |
TAG

Division of Health Service Regulation
STATE FORM

1D
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

R-C
06/06/2025

RESS. CITY. STATE. ZiP CODE

(x5)
COMPLETE
ATE

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

OEHS11 if continuation sheet 24 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025

FORM APPROVED.

V 367) Continued From page 20

of all level I!I 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:

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

(2) restrictive interventions that do not meet the
definition of a level I! or level Ill incident:

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

| 6) the total number of level |! and level II!
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

|

Vv 367

(x1) PROVIDERI/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHL013-240

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS. CITY. STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

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

(x4) 1D
PREFIX
TAG

Division of Health Service Regulation
STATE FORM

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

OEH511

(X3) DATE SURVEY

COMPLETED

R-C
06/06/2025

(x5)
COMPLETE
DATE

If continuation sheet 25 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

V 367)
| Continued From page 21

| This Rule is not met as evidenced by:

| Based on record reviews and interviews, the

| facility failed to report all level Il and Ii! incidents
in the Incident Response Improvement System
(IRIS) and notify the Local Management Entity

| (LME)/Managed Care Organization (MCO)
responsible for the catchment area where
services as required. The findings are:

| Review on 5/22/25 of “Notification of CPS (Child

Protective Services) Involvement" dated 4/1/25

revealed:

| -". Allegedly, the female group home staff
member (Staff #4) kissed the 17 year old child
(Former Client (FC) #1) on her lips. Female staff
(#4) went into the child's (FC #1) room, turned off
the lights and undressed and attempted to touch
her, child pushed away..."

| Review on 5/27/25 of FC #1's record revealed:

| -Age 17.

-Admitted 10/24/24

-Diagnoses: Major Depressive Disorder, Mild
Intellectual Disabilities, Oppositional Defiant
Disorder.

-Discharged 3/27/25

-Discharge Summary, completed 3/27/25 by
Former Qualified Professional (FQP):
-"Discharge Disposition-Since her (FC #1) arrival
(10/24/24), [FC #1] has exhibited extreme
behaviors on a daily basis to include sexual
inappropriateness with peers, staff, teachers, and
school administrators, manipulation, staff
splitting, compulsive lying, false claims of sexual
assault, property destruction, aggression,
profanity, noncompliance, multiple AWOL (absent
without leave) attempts, physical assaults, verbal
abuse, spitting, staff intimidation, etc. To ensure

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLIA| (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY

TION NUMI
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R-C

MHL013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

PREFIX
DATE

TAG

(%4) 1D | SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (x5)
|
|
|

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

Division of Health Service Regulation
STATE FORM sto60 OEHS11 If continuation sheet 26 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

Vv 367 | Vv 367

| Continued From page 22

safety for both [FC #1] and others in the home,

the Resident was discharged from the facility

because the resident was physically and verbally

aggressive, displayed property destruction,

attempted to go awol, and made multiple self-
harm attempts and threats."

| "Course of Treatment ...Since admission

| (10/24/24) to level three services, the resident

| has shown constant regression to include |

instances of property destruction, verbal and

physical aggression, attention-seeking behaviors, |

false allegation of sexual assault [van driver,

school officials, residential staff (facility staff)],

AWOL attempts, suicidal ideations, and self-harm

attempts resulting in multiple hospitalizations ...

-Discharge Plan-The resident was IVC‘d

(involuntarily committed), and [Facility] will |

| support the transition to a higher level of care

| and/or alternate placement.

-Discharge Outcome-Discharged-Regression.”

Review on 5/22/25 and 6/6/25 of the North |
| Carolina Incident Response Improvement System |

(IRIS) from 1/1/25-6/6/25 revealed: |
-3/27/25 FC #1 walked away from the facility, |
threatened self-harm, threatened harm to others | |
in the facility which and her behaviors resulted in
call to law enforcement outcome of involuntary | |
commitment |

Review on 6/5/25 of the Facility Police Calls for
Service Report 1/1/25 through 6/5/25 revealed: -
1/5/25, 16:10 (4:10pm), Domestic Assault,
[Former Staff #7 (FS#7)], W911, Notes: no signs
of suicidal ideology, group home employees are |
going to work on obtaining IVC paperwork on the
juvenile (FC #1). They (facility) were advised that
we (law enforcement) are not able to transport |
her (FC #1) without the IVC paperwork from the | |
mags (magistrate) office: Caller is member of the |

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: PORULOING COMPLETED

R-C

MHL013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(4) 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 \ ONE

DEFICIENCY) |

Division of Health Service Regulation
STATE FORM 898 OEH511 If continuation sheet 27 of 31

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

v367)

| Continued From page 23

| group home staff (FS #7); No Weapons; 17 YOA

| (years of age) F/M; mixed female subj (subject)

| has beat up alll of the staff. has spit on the caller

| (FS #7) and made threats to other reside
(clients)."
-1/24/25 13:51 (1:51pm), Child Abuse Complaint,
Self (facility), Notes: Not on scene. Intake report
-1/24/25, "18:46 (6:46pm), Missing Person [Staff
#1), E911, Notes: Upon arrival | spoke with the
house manager (HM/QP#2), [HM/QP#2] who
stated at approximate 6:15 pm [Former Client #3
| (FC#3)] left the residence (facility)...While on site
taking notes for the 81 report [FC #3]. She
(FC#3) she needed to get away for the moment
and went to [fast food restaurant]. [FC#3] stated
she would not leave the residence (facility) again
and would remain in side; Arrived back home
(facility)...19:25 (7:25pm); [FC#3] WF (white
female) blonde and bik (black) hair, blk jacket
| and furry slides, oversized jackets, walking
towards [local restaurant], time lapse 20mins
(minutes)."
-2/8/25, 15:43 (3:43pm), Missing Person Child,
[FS#8], W911, Notes: Juvenile (FC #3) left in the
| care of para professional [Staff #9], who stated
| she will be transporting the juvenile to [County] for
further evaluation and placement, [FC #3];
Notified 2/8/25, 15:48 (3:48pm) twrds (towards)
shopping center black hoodie, navy blue baby
_ yoda pajama pants, [sneaker brand] shoes blk
and gry (grey) bag, and red crossbody purse left
on foot client ran away, 15 year old whit female
[FC#3)."
-3/21/25, "22:57 (10:27pm), Check Welfare, [Staff
#6), Notes:...One female juvenile (FC #1);
Prisoner in custody, 23:01 (11:01pm); Back at the
home (facility) but needs transport her to hospital;

heavy set female short Mohawk hair style [FC #1]

| 17 yo (year old); Female jumped out the window,
| subject have a 73 episode (mental distress)." |

V 367

STATEMENT OF DEFICIENCIES (K1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

fr
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHL013-240

R-C
06/06/2025

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

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Division of Health Service Regulation

PROVIDER'S PLAN OF CORRECTION x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE:
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

STATE FORM 6899 OEH511 if continuation sheet 28 of 31

PRINTED: 06/18/2025
FORM APPROVED

Division of Health Service Regulation

Vv 367 | Continued From page 24

-3/25/25, "19:15 (7:15pm), General Disturbance
; [QP#1], Notes: | located [FC #1] on the ramp of
[interstate highway]. She voluntarily got in my car
and returned to the group home where | turned
her over to staff. [FC #1] state she was not going
to hurt herself and just wanted to leave for a
while. She stated she would remain at the group
home for the evening (19:59, 7:59pm); On
{interstate highway]...female flagged me
down...walking...caller lost sight, caller in a gray
[make/model]; history of self harm trying to walk
in between cars short haircut heavy set female
green shorts and purple jacket...female trying to
run off group home no known weapons [FC #1]
17 yo female."
-4/2/25, "9:45am, Child Abuse Complaint, Self;
Notes: DSS (Department of Social Services)
report; 3/27/25 18:56 (6:56pm) Mental
Commitment, Notes: [FC #1]...”

Reviews on 5/22/25 of the facility's records 2/1/25
through 5/22/25 revealed:

-No level Il or Ill incidents reported.

-No documentation of internal investigations for
level Il, and Ill from 3/1/25 through 6/6/25.

Attempt interview on 6/4/25 with Former Qualified
Professional (FQP) was unsuccessful, left voice
message with contact information for follow up
and there was no contact. There was no return
call prior to survey exit.

| Interview on 6/4/25 with Staff #4 revealed: -
| Was not responsible for submitting reports in
| IRIS.

-Had never written or submitted an incident
report.
| -QPs were responsible for submitting reports in
IRIS.

STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A, BUILDING
R-C

MHLO013-240 06/06/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (5)
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 SATE

DEFICIENCY)

Division of Health Service Regulation
STATE FORM one OEHS511 If continuation sheet 29 of 31

PRINTED: 06/18/2025
FORM APPROVED.

_Division of Health Service Regulation
T

V367) Continued From page 25 vser |

Interview on 6/2/25 with the Home |

Manager/QP#2 revealed: |

-Qualified Professional (QP)

-She and QP #1 were responsible for reporting

incidents.

-Was unable to provide the facility's internal

incident reports.

_ -Was not aware if there had been a report
submitted in IRIS for FC #1's 4/1/25 allegation of |
Staff #4 kissing and attempting to touch FC #1.

Interview on 6/2/25 and 6/4/25 with the QP#1 |

revealed: |

-Was responsible for submitting incidents in IRIS

-Had submitted IRIS report for FC #1's IVC on

3/27/25 and had not submitted any other level I!

| and III reports to IRIS.

| -Was not aware she needed to submit report in

| IRIS and HCPR for FC #1's 4/1/25 allegation of
Staff #4 kissing and attempting to touch FC #1. -
Had not submitted any other level I! or Ill reports in

| IRIS for FC #1 behaviors as described in FC #1's |

3/27/25 discharge summary. | |

-Did not have documentation of incident reports |

to correspond with police service calls to the

facility (1/1/25 to 6/5/25). | |

| Resources/Compliance Consultant revealed:
-Contracted consultant.

-Responsible for overseeing the reporting of
incidents.

-Did not submit report in IRIS and was not |
responsible for submitting IRIS reports.
-"Generally the QP (QP#1) would be responsible,
| would receive a copy to keep track and make
sure the follow-through is taken care of...| provide
them (facility) with the information, then follow up |
to make sure it is done.”
-Was not aware of incidents from police report |

Interview on 6/4/25 and 6/6/25 the Human

STATEMENT OF DEFICIENCIES (K1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BURLBING COMPLETED

R-C
MHLO13-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(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
Ta | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE:

| DEFICIENCY)

|

Division of Health Service Regulation
STATE FORM bad OEH511 If continuation sheet 30 of 31

Division of Health Service Regulation

V 367} Continued From page 26

| (1/1/25 through 6/5/25)

| -Was not aware that QP#1 had not provided
internal incidents documentation prior to survey
exit.

| This deficiency constitutes a re-cited
| deficiency and must be corrected within 30
| days.

V 367

PRINTED: 06/18/2025
FORM APPROVED

Signature: Steven Lanham
Email: farugam31073@gmail.com
Title: CEO

Division of Health Service Reguiation
STATE FORM

OEHS11

If continuation sheet 31 of 31

inspection_type: MHLCS Complaint and Follow-up