summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation

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

MHLO13-251

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

(X3) DATE SURVEY
COMPLETED

c
B.WING 07/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

PEACEFUL WAYS

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES

PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL
Tac | REGULATORY OR LSC IDENTIFYING INFORMATION)

INITIAL COMMENTS

| Acompliaint survey was completed on 7/17/25.
| Four complaints were substantiated (intakes
#NC00230491, NC00232280, NC00232213,
NC00232283), and one complaint was

| unsubstantiated (intake #NC00232206).

| 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 4 and has a current
census of 3. The survey sample consisted of
| audits of 3 current clients and 1 former client.

27G .0202 (F-1) Personnel Requirements

| 10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be documented.
(g) Employee training programs shall be

| provided and, at a minimum, shall consist of the
following:

(1) general organizational orientation;

| (2) training on client rights and confidentiality as
| delineated in 10A NCAC 27C, 27D, 27E, 27F and
410A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the
client as specified in the treatment/habilitation
plan; and

| (4) training in infectious diseases and

| bloodbome pathogens.

| (h) Except as permitted under 10a NCAC 27G

| .5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all

| times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained
Division of Health Service Regulation

fe, = P .
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S sour A Tine am. Sif ane Lento al
Teco

STATE FORM

1D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

7%

G6K611 if continuation sheet 1 of 67

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

Division of Health Service R

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

gulation
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

MHLO13-251

(x4) ID
PREFIX
TAG

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

Continued From page 1

to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,
the American Heart Association or their
equivalence for relieving airway obstruction.

(i) The governing body shall develop and
implement policies and procedures for identifying,

| reporting, investigating and controlling infectious
| and communicable diseases of personnel and
| clients.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure at least one staff member who
was trained in basic first aid (FA) and
cardiopulmonary resuscitation (CPR) was
available in the facility at all times when a client
was present for 3 of 6 audited staff (former staff

| (FS) #1, staff #3, and staff #5). The findings are:

| Review on 6/30/24 of (FS) #1's personnel file

revealed:

| -Direct Care Specialist.

-Hire date of 4/9/25.
-Termination date of 7/7/25.

| -American Heart Association CPR card dated

4/14/25.
-No American Heart Association FA card.

Review on 7/9/25 of staff #3's personnel file
revealed:

| -Direct Care Specialist.

-Hire date of 6/4/25.
-CPR/FA Certificate signed by CPR/FA trainer
dated 3/27/25.

Division of Health Service Regulation

STATE FORM

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

6809

PRINTED: 07/28/2025
FORM APPROVED

(x3) DATE SURVEY
COMPLETED

c
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

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

V 108 27G .0202 (F-I) Personnel
Requirements

All staff who were cited as not
having in person CPR in perso
training with complete the in-
person portion training by
9/15/25

The facility will maintain a CPR
training log track staff
certification status and
expiration dates.

Scheduling procedures have
been revised to ensure at least
two certified staff is present or
every shift. Completed July 18,
2025

*Please not all staff were
trained prior to their start date
Files only included offer letters
and not record of actual start
dates of which the facility was
not asked

Program Director (or designate
will oversee staff training and
scheduling compliance

G6K611 if continuation sheet 2 of 67

PRINTED: 07/28/2025

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

c
MHL013-251 8. WING ____. 07/17/2025

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

PEACEFUL WAYS
KANNAPOLIS, NC 28083

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD 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)

Continued From page 2 Vv 108

-American Heart Association CPR card dated
3/27/25.
-No American Heart Association FA card.

Review on 7/14/25 of staff #5's personnel file

revealed:

-Direct Care Specialist.

-Hire date of 3/19/25.

-CPR/FA Certificate signed by CPR/FA trainer
dated 6/4/25.

-American Heart Association CPR card dated
6/4/25.

-No American Heart Association FA card.

Interview on 7/2/25 with FS #1 revealed:

-Had worked alone in the facility.

-Frequently worked 4pm to 11pm with staff #3.
-Watched a PowerPoint presentation on the
computer for CPR/FA.

-Did not receive the in person demonstration
portion of the training.

-Did not practice CPR on a mannequin.

Interview on 7/2/25 with staff #3 revealed:

| -Had worked alone in the facility and transported
clients alone.

-Frequently worked 4pm to 11pm with FS #1.
-CPR/FA was completed on the computer in a
Zoom class.

-Did not receive the in person demonstration
portion of the training.

-Did not practice CPR on a mannequin.

Interview on 7/7/25 with staff #5 revealed:
| -Had worked alone in the facility. |
-Completed CPR/FA training virtually on the |
| computer.

-Did not receive the in person demonstration
portion of the training.

-Did not practice CPR on a mannequin.
Division of Health Service Regulation

STATE FORM 6699 G6K611 If continuation sheet 3 of 67

Division of Health Service R

(x4) 1D
PREFIX |
TAG

Vv 108

V 110)

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-251

B. WING

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

(X3) DATE SURVEY
COMPLETED

c
07/17/2025

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

Continued From page 3

| Interview on 7/7/25 with the CPR/FA Trainer

revealed:

-Contracted with the facility to provide CPR/FA
training.

-Taught FA and CPR on the same day, but only
got the CPR cards (not the FA cards) from the
American Heart Association because it was
cheaper.

-Provided the facility with a computer printed FA
certificate.

-Sometimes taught CPR/FA virtually on the
computer.

-Utilized role playing when teaching virtual
classes.

-Participants used a "teddy bear or baby doll" for
the demonstration portion during virtual training.

Interview on 7/14/25 with the Director/Associate
Professional revealed:

-FA/CPR training should include an in person
component.

-Did not have staff sign in sheets.

27G .0204 Training/Supervision
Paraprofessionals

410A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements for
paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.

(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by the
population served.

(d) At such time as a competency-based

Division of Health Service Regulation

STATE FORM

i)
PREFIX
TAG

G6K611

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

If continuation sheet 4 of 67

PRINTED: 07/28/2025
FORM APPROVED

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

Division of Health Service R

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

c
07/17/2025

B. WING

MHLO13-251

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
CEFUL WAYS KANNAPOLIS, NC 28083

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID | 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)

Continued From page 4

employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.

(e) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge; V 110 27G .0204 Training/Supervision

(2) cultural awareness: Paraprofessionals

(3) analytical skills;

(4) decision-making; All paraprofessionals

(5) interpersonal skills; will participate in

(6) communication skills; and refresher training on the
(7) clinical skills. skills required for

(f) The governing body for each facility shall working with the Level 3
develop and implement policies and procedures population (including

for the initiation of the individualized supervision trauma-informed

plan upon hiring each paraprofessional. practices, crisis

prevention, de-
escalation, and client |
rights) within 30 days
(by September 30th).

A competency checklist
will be implemented for
all direct care staff, to be
completed upon hire
and annually thereafter,
ensuring staff

This Rule is not met as evidenced by:

Based on record review and interview, 1 of 5
audited paraprofessionals (Licensee/Direct Care
Specialist) failed to demonstrate the knowledge,
skills and abilities required by the population

served. The findings are: demonstrate the
knowledge and skills
Review on 6/30/25 of the Licensee/Direct Care required by the |
Specialist's personnel file revealed: population served.
-Hire date of 6/28/21.
-Evidence Based Protective Interventions-Base Supervisors will provide |
Plus (EBPI) 2/3/25. monthly coaching and |
feedback sessions with
Interview on 7/3/25 with former client (FC) #2 paraprofessionals to
revealed: reinforce skills and
~"[Licensee/Direct Care Specialist] communicated address performance |

threats to me and [client #3]

Division of Health Service Regulation
STATE FORM iat G6K611 if continuation sheet 5 of 67

concerns early.

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
07/17/2025

B. WING

MHLO13-251

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

PEACEFUL WAYS 518 EAST C STREET
KANNAPOLIS, NC 28083
(xayiD | SUMMARY STATEMENT OF DEFICIENCIES | i) | 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)

Continued From page 5 Vv 110

-"He (Licensee/Direct Care Specialist) said (to

| me), ‘You are coming willingly or forcefully,’ and
took everything out of his pockets.”

-"| think he wanted me to come inside (facility). |
was on the front porch because [client #1] was
running his mouth."

-The licensee/Direct Care Specialist made a
similar statement to client #3 in a separate
incident (date unknown).

Interview on 7/1/25 with client #3 revealed:
-Locked himself in his room because he did not
"want to go on a community outing.

-The Licensee/Direct Care Specialist "came and
busted down the door."

-Told the Licensee/Direct Care Specialist, "| don't
want to go anywhere.”

-"He said, "You will come willingly or forcefully.”
-The Licensee/Direct Care Specialist made the
same comment (You will come willingly or
forcefully) to [FC #2] 2 weeks later (date
unknown).

-The Licensee/Direct Care Specialist handed his
keys to somebody like he was going "to do
something” to FC #2.

| Interviews with client #1 and #4 on 7/1/25
revealed:

-Denied hearing the Licensee/Direct Care
| Specialist make threats to clients.

Interview on 7/9/25 with the Licensee/Direct Care
Specialist revealed:

-Arrived at the facility and all of the clients were
on the front porch (date unknown).

-Was attempting to deescalate the situation and
get the clients to go inside.

-FC #2 "started cursing and said, 'l don't want to
be here.”

-l told him you can go "willingly or we can get the
Division of Health Service Regulation

STATE FORM ones G6KE11 If continuation sheet 6 of 67

(x4) 1D
PREFIX
TAG

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-254

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET

PRINTED: 07/28/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
c
8. WING 07/17/2025

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

KANNAPOLIS, NC 28083

1D |

PREFIX
TAG

——EEE

Continued From page 6

police to make you go in (the facility)."

-FC #2 complied and the police were not called.
-Client #3 did not want to go to the gym (date
unknown).

-Had to "bust" the door open.

-Staff didn't know if he was self-harming.
-Talked to client #3 and he went to the gym.

Interview on 7/17/25 with the Director/Associate
Professional revealed:

-It would not be appropriate for a direct care staff
to threaten a client to move him willingly or
forcefully.

27G .0205 (C-D)
Assessment/Treatment/Habilitation Plan

410A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.

(d) The pian shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement,

(2) strategies;

(3) staff responsible;

(4) a schedule for review of the pian at least
annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessment of
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be

Division of Health Service Regulation

STATE FORM

V 110

V2

one G6K611

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

{f continuation sheet 7 of 67

Division of Health Service Requlation

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

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

xa) iD |
PREFIX |
TAG

MHL013-251

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

Continued From page 7
obtained.

This Rule is not met as evidenced by:

Based on observation, record review and
interview, the facility failed to develop and
implement goals and strategies to meet the
needs of 1 of 3 audited clients (#1). The findings
are:

Review on 6/27/25 of client #1's record revealed:
-Admission date of 4/11/25.

-13 years old.

-Diagnoses of Conduct Disorder, Unspecified;
Trauma and Stressor Related Disorder; Attention
Deficit Hyperactivity Disorder, Combined
Presentation.

~Comprehensive Clinical Assessment (CCA)
Addendum dated 3/18/25: History of being absent
without leave (AWOL).

-Treatment Plan dated 10/28/24 and updated
5/7/25 and 6/5/25: "[Client #1] does not currently
have access to any unsupervised community
areas.” No goals or strategies for AWOL

behaviors.

Review on 6/30/25 of the North Carolina Incident
Response Improvement System from 4/1/25 to

| 6/30/25 revealed:

-5/30/25 "At approximately 6:00 PM, staff
prompted all clients to begin their scheduled
chores as outlined in the house routine. [Client

Division of Health Service Regulation

STATE FORM

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

c
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

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

V 112 27G .0205 (C-D)
Assessment/Treatment/Habilitati
Plan

The client's treatment plan will br
updated to include a goal and

specific interventions to address
AWOL behavior. Updated 8/1/25

The Qualified Professional (QP)
reviewed the updated plan with
staff to ensure consistent
implementation and
documentation.

The facility will review all active
client treatment plans to ensure
goals and strategies are present
for each identified need or high-
risk behavior (e.g., AWOL,
aggression, self-harm, substance
use).

Program Director will oversee
treatment plan audits and provid
final approval.

All client treatment plans will be
reviewed and updated by within
30 days-Completed 8/1/25

Any discrepancies will be
corrected immediately, and
findings will be discussed during
staff meetings for accountability.

GBK611 {f continuation sheet 8 of 67

PRINTED: 07/28/2025

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
c
MHL013-251 B. WING _________ 07/17/2025

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

PEACE! XY:
mata KANNAPOLIS, NC 28083

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 8)

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

| DEFICIENCY)

vit2) Continued From page 8 v 112
| #1] was observed not completing his assigned
task. Staff approached to model the expected |
behavior and offer support. [Client #1] became
visibly upset and stated that he would not
complete the chore. Staff |
documented the behavior and redirected attention
to assisting other clients. [Client #1's] agitation
escalated following a point deduction for
noncompliance. Without permission, he exited
the home, retrieved a metal pole from outside the
premises, and charged at staff in a threatening
manner. He then used the pole to strike and
damage household furniture. Staff attempted
verbal de-escalation techniques and redirection;
however, [client #1] exited the home again
without authorization. He remained in view across
the street but eventually left the area around 8:00
PM. Staff searched the neighborhood by foot and
vehicle for approximately 45 minutes but were
unable to locate the client. Law enforcement was
contacted at 9:00 PM. At approximately 9:15 PM,
local police retumed [client #1] to the group home
(facility). Staff engaged in processing with the |
client, during which he shared that his emotional
outburst was triggered by his friend moving away.
[client #1] was redirected to complete his
nighttime hygiene routine and go to bed, which he
did without further incident."
-6/3/25 "[Client #1] went AWOL following an
incident involving another consumer. The initial |
incident was de-escalated by staff; however,
shortly after, [client #1] became aggressively
upset and disregarded staff directives to remain
inside the home. [Client #1] exited the residence
without staff permission. [Client #1] remained
within staff line of sight for approximately 15 to 20
minutes before leaving the visible area. Staff
immediately conducted a search for the client
both on foot and by vehicle for 45 minutes but
were unsuccessful in locating him. At
Division of Health Service Regulation
STATE FORM coe G6K611 {f continuation sheet 9 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

Cc
B. WING 07/17/2025

MHLO013-251

NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE
§18 EAST C STREET
KANNAPOLIS, NC 28083

PEACEFUL WAYS

(xa) iD | 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)

V 112, Continued From page 9 v112

approximately 8:00 p.m., law enforcement was
notified in accordance with facility policy and
protocol, as [Client #1] had exceeded the
allowable time away without supervision. At
approximately 1:06 a.m. the following moming,
[Client #1] was returned to the home (facility) by
| police. He was unharmed upon retum."

Interview on 7/1/25 with client #1 revealed:
~"Sometimes staff or kids (clients) piss me off and
1 go AWOL."

-Left the facility "4 or 5 times” without supervision.
~"| went to downtown {local town] to look for
friends. Found a $10 bill so | bought myself
food.”

-Was gone for about 3 hours each time.

-Staff did not make any changes to prevent
AWOLs.

Interview on 7/2/25 with former staff #1 revealed:
Client #1 did not have goals or strategies to
prevent AWOL behavior.

Interview on 7/1/25 with staff #3 revealed:
-Client #1 did not have goals or strategies to
prevent AWOL behavior.

-No changes were made to the treatment plan to
prevent AWOL behavior.

-Was instructed to keep clients who went AWOL
"in sight as much as we can. We (staff) at least
go to the end of the block and if they don't come
back in at least 40 minutes we call the
authorities.”

Interview on 7/8/25 with the Qualified
Professional revealed:

-Was not sure if client #1's treatment plan had
goals and strategies to address AWOL behavior.
"I would have to check documentation. “He
(client #1) had a history of AWOL." | want to say
Division of Health Service Regulation

STATE FORM Lad G6K611 if continuation sheet 10 of 67

PRINTED: 07/28/2025
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

(s3
MHLO13-251 eee 07/17/2025

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

KANNAPOLIS, NC 28083

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ] ID 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)

PEACEFUL WAYS.

V 112| Continued From page 10 Vv 112

that there were goals in place.”

-Had not made revisions to client #1's treatment
plan to include goals and strategies to address
AWOL behavior.

Interview on 7/1/25 and 7/8/25 with the
Director/Associate Professional revealed:

-Client #1 had a history of AWOL behavior prior to
being admitted to the facility.

-Client #1 did not have goals or strategies to
prevent AWOL behavior in his treatment plan.

- Client #1's treatment plan would be updated in
July 2025 to add a goal and strategies to address
the AWOL behavior.

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

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

(g) Health care facilities shall 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:

| a. Neglect or abuse of a resident in a 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 facility.

| d. Diversion of drugs belonging to a health care
i

Division of Health Service Regulation
STATE FORM ba G6K611 Mf continuation sheet 11 of 67

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(X4) ID
PREFIX
TAG

MHL013-251

B. WING.

518 EAST C STREET

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

Continued From page 11

facility or to a patient or client.

|e. Fraud against a health care facility or against
| 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 to 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 all allegations or acts of abuse,

| neglect or exploitation, including injuries of an

unknown source were investigated, failed to
make every effort to protect clients and failed to
ensure the results of all investigations were
reported to the HCPR within five working days
from the initial notification to the Department.
The findings are:

Finding #1:

Review on 6/27/25 of client #1's record revealed:
-Admission date of 4/11/25.

-13 years old.

-Diagnoses of Conduct Disorder, Unspecified;
Trauma and Stressor Related Disorder; Attention
Deficit Hyperactivity Disorder, Combined
Presentation.

Review on 7/9/25 of staff #3's personnel file
revealed:

-Direct Care Specialist.

-Hire date of 6/4/25.

-Evidence Based Protective Interventions
(EBPI)-Base Plus 6/4/25.

Division of Health Service Regulation
STATE FORM

ID
PREFIX
TAG

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING:

COMPLETED

c
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

KANNAPOLIS, NC 28083

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

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

* The Program Director

immediately reviewed all pending ar
recent incident reports to confirm th
required investigations and reportin:
were completed on 7/19/25

* Clients involved in any

allegations were assessed for safety,
and protective measures (increased
supervision, staff reassignments,
and/or removal of implicated staff fr
client contact) were immediately
implemented. Completed 7/19/25-
7/25/25-\nplicated employee
terminated 7/7/25

The cited case was reported to
HCPR with supporting documentatic
Completed 7/14/25

All staff, supervisors, and QPs will
receive refresher training on ANE
reporting requirements, including
documentation, client protection, an
timelines, within 10 business days.
(Done 7/24/25)

¢ Program Director: ensures
protective measures and reporting
compliance.

* Qualified Professional (QP):
conducts and documents
investigations.

G6K611 If continuation sheet 12 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

Cc
07/17/2025

MHLO13-251

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) 1D 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)

Continued From page 12

Review on 6/30/25 of the North Carolina Incident
Response Improvement System (IRIS) from
4/1/25-6/30/25 revealed:

-"On June 26, 2025, at approximately 8:52 PM,

| the Director (Director/Associate Professional (AP)
was notified by staff (#3) that an altercation had
occurred between staff (former staff (FS) #1) and
client (#1) during evening chores. Staff (#3)
reported that law enforcement had been called.
The Qualified Professional (QP) arrived on site
within 30 minutes, and the Director (Director/AP)
followed shortly after. Police were already
present. Upon arrival, client (#1) was seated on
the porch with visible surface scratches to the
chest, which did not require medical attention.
Staff (FS #1) was in the yard and reported no
injuries. [Client #1] stated he was washing dishes
when staff (FS #1) began rushing him. When he
didn't comply, [ FS #1] removed the dish rag from
him and sat down. [Client #1] retrieved the rag
and resumed cleaning. [FS #1] returned to the
kitchen, yelling. [Client #1] sprayed her with
water, which escalated into physical contact,

| including pushing and exchanging blows. The
conflict moved outdoors before they were
separated ...Staff (#3) was present during the |
incident but did not intervene and left the scene
when police arrived. Both client (#1) and staff (FS
#1) were assessed for injury by OP and Director
JAP."

Review on 7/2/25 of video #1 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 28 seconds long. |
-In the living room, FS #1 was struggling with
client #1 on the sofa and was pulling client #1’s
hair.

-Both of FS #1's hands were holding client #1's
hair.

-FS #1 was on top of client #1.

Division of Health Service Regulation

STATE FORM co G6K611 Mf continuation sheet 13 of 67

Division of Health Service Regulation

PRINTED: 07/28/2025
FORM APPROVED

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

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS:

(x4) ID
PREFIX
TAG

MHLO013-251

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING: COMPLETED

c
07/47/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET

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

Continued From page 13

-Staff #3 was yelling at client #1 to stop and
telling him "Police are coming and they are going
to take your a*s to jail."

-Client #1 said, "Tell her to get the f**k off me."
-Staff #3 said, "If she gets off of you what ...
(unintelligible)."

-FS #1 got off the sofa, continued to grip and pull
client #1's hair with both hands.

-Staff #3 said, "What benefit?" and yelled, "Stop,
oh my God.”

-Client #1 and FS #1 continued to struggle with
one another until the video ended.

- Staff #3 did not attempt to physically intervene.

Review on 7/2/25 of video #2 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 33 seconds long.

-FS #1 was on the floor pulling client #1's hair
with both hands.

-FS #1 and client #1 continued to struggle with
one another as FS #1 wrapped her legs around
Client #1's legs as she was pulling his hair.

| -Client #1 slapped FS #1 on the right shoulder

and FS #1 released Client #1's hair.

| -FS#1 then kicked client #1's head while they

were still both on the floor.

-An unknown person yelled, "You are on your own
[client #1].”

-Client #1 got to his feet and moved away from
FS #1.

-FS #1 grabbed client #1's ankle when client #1
attempted to kick her.

| -Staff #3 said,"[Client #1], s**t, stop, stop.”
| -Client #1 grabbed a football and threatened to
| throw it at FS #1's head.

-Staff #3 did not attempt to physically intervene.
-The video ended.

Interview on 7/1/25 with client #1 revealed:
-On 6/26/25 FS #1 took away the dish rag while

KANNAPOLIS, NC 28083

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

STATE FORM

Division of Health Service Regulation

had G6K611 If continuation sheet 14 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BULLDING: COMPLETED

Cc
MHLO13-251 B. WING 07/17/2025

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

PEA ‘UL
CEFUL WAYS KANNAPOLIS, NC 28083

(x4) ID 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)

Continued From page 14

he was doing dishes.

| -FS #1 "pushed me" and "I pushed her back."
-FS #1 "hit me in the stomach or chest so |
started hitting her back."

| "Had a few scratches on my chest and one on
my arm and forgot were the rest of the scratches
were.”

- FS #1 “pulled out chunks of my hair in little balls
everywhere.”

-Staff #3 did not physically intervene to stop FS
#1.

Interview on 7/1/25 with client #3 revealed:

-On 6/26/25, client #1 was cleaning his dishes.
-Heard arguing and saw FS #1 “snatch” the dish
towel.

-FS #1 went to her seat and client #1 tried to
“grab her.”

-FS #1 "pushed" client #1.

-Client #1 and FS #1 “started tussling-grabbed
each other pulling hair, kicking."

-They were fighting, wrestling on the floor for
about 8 minutes. "Somehow it ended up
outside."

-Staff #3 called the law enforcement and
recorded some of the altercation.

-Staff #3 "stayed for 3 minutes to talk to the cops
and pulled off (left facility) and said, she quit.”

Interview on 7/1/25 with client #4 revealed:

-On 6/26/25 there was an argument and a
“physical altercation” between client #1 and FS
#1.

-Staff #3 called the police and "filmed the whole
thing.”

-Staff #3 "told them (FS #1 and Client #1) to
stop.”

Interview on 7/2/25 with FS #1 revealed:

~On 6/26/25 client #1 was washing dishes and
Division of Health Service Regulation

STATE FORM oe G6K611 continuation sheet 15 of 67

PRINTED: 07/28/2025

FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPUIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER a BLN: COMPLETED
c
MHL013-251 B. WING _________ 07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(xayio | 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)
i ne EU EEE |

Continued From page 15 V 132

playing in the sink when she told him to go to bed.
- She and client #1 argued back and forth about
turning off the water until client #1 “pushed and
shoved" her.

- She grabbed client #1 by his hair “trying to
restrain him.” |
| - They continued to struggle with one another and
ended up outside on the facility's porch.

-Staff #3 did not help.

- Staff #3 recorded the incident and called the |
police.

- When the police arrived, staff #3 explained her
part and "left (facility).”

- Staff #3 would not give out any information (to |
the police), "like her address.”

Interview on 7/2/25 with staff #3 revealed:

-On 6/26/25, Client #1 was washing dishes when
FS #1 "was asking [client #1] to get ready for bed.
He told her no.”

-FS #1 and Client #1 "started going back and
forth" verbally.

-"I told him (client #1) to do dishes and her (FS
#1) to calm down.” i

- When Client #1 continued to play in the water,
FS #1 tuned the water off.

- Client #1 sprayed FS #1 with the water and said,
"Do you want to have a water fight."

- FS #1 pushed client #1 and they both started
“pushing and shoving.”

-"[Client #1] was choking [FS #1]. | wasn't
recording at this time.”

~"I called the police.”

- FS #1 and Client #1 "continued to fight like
strangers.”

- FS #1 was "pulling client #1's hair. Some of it
came out.” |
- Client #1 grabbed a football and threw it at FS |
#1. "I didn't want to trigger him, so | stopped
recording.”

Division of Health Service Regulation

STATE FORM om G6K611 if continuation sheet 16 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(x3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
07/17/2025

B. WING

MHL013-251

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
PEACEFUL WAYS

KANNAPOLIS, NC 28083

(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)

Continued From page 16

- Client #1 threw the football at FS #1's face and
they "started fighting again."
- "lL opened up the door (facility) and heard
sirens.”

-"[Client #1] grabbed a stick and attempted to hit
(FS #1), and they tussled with the branch (stick).”
~"| told them to put the branch down, and they
did.”

- After the police arrived, she let the officers know
that the Director/AP and Licensee/Direct Care
Specialist were on their way and then "| left
(facility).”

| -"| didn't want to help or assist when she (FS #1)
is fighting. It would look like we were ganging up
on him (client #1).”

-"As soon as they (FS #1 and client #1) were
tussling, | jumped up and told them to calm down.
Nobody listened so, | called 911."

-"Later on, | pulled out my phone to record.”

| -"I didn't get (record) the beginning and didn't get
the part on the porch."

Interview on 7/8/25 with the Director/AP revealed:
- Arrived at the facility on 6/26/25 and staff #3 had
already left.

- Started the investigation into FS #1's actions
during the incident immediately and concluded
that FS #1 “did not follow de-escalation protocol
putting a client (#1) at risk."

-"| haven't been able to substantiate whether or
not she (Staff #3) intervened."

- Staff #3 recorded a video but did not share it
with facility staff.

- Staff #3 had not responded to attempts to reach
her.

- "[Staff #3] indicated that she quit."

- "I was going to officially terminate her."

~"She (FS #1) won't be back, but | haven't
officially given her anything (termination notice)
because | haven't gotten her side of the story.”
Division of Health Service Regulation

STATE FORM son G6K611 M continuation sheet 17 of 67

PRINTED: 07/28/2025
FORM APPROVED

R

qulation
(X1) PROVIDER/SUPPLIERICLIA
(DENTIFICATION NUMBER:

Division of Health Service

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

c
07/17/2025

B. WING

MHL013-251

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

PEACEFUL WAYS
KANNAPOLIS, NC 28083
(xa) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES ID 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)

Vv 132 | Continued From page 17 Vv 132

| Interview 7/9/25 with the Licensee/Direct Care

| Specialist revealed:

-FS #1 did not “respond appropriately” during the
incident with client #1 on 6/26/25.

-FS #1 was terminated for lack of de-escalation
techniques and the wrong use of EBPI."

-Client #1 had some superficial scratches and

| hair pulled out. Client #1 "declined" medical
treatment.

-Staff #3 "claims she didn't see anything and
"claims she tried to deescalate."

-"The police said [staff #3] had video. How are
you deescalating when you are recording?” |
-Staff #3 was "let go" because of neglect.
-Staff #3 was in the area (of the incident) but
started recording and failed to deescalate or
intervene when the verbal escalation started.
-"You are supposed to intervene."

Finding #2:

Review on 6/30/25 of the Licensee/Direct Care
Specialist personnel file revealed:

| -Hire date of 6/28/21.

-EBPI-Base Plus 2/3/25.

Review on 6/24/25 of former client (FC) #2's
record revealed:

-Admission date of 3/21/25.

-17 years old.

-Discharge date of 6/23/25.

-Diagnoses of Post-Traumatic Stress Disorder,
Conduct Disorder.

Interview on 7/3/25 with FC #2 revealed:
-"[Licensee/Direct Care Specialist] communicated
threats to me and [client #3]."

~"He (Licensee/Direct Care Specialist) said (to FC
#2), "You are coming willingly or forcefully,‘ and
Division of Health Service Regulation

STATE FORM = G6K611 {f continuation sheet 18 of 67

es es

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X@) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
MHL013-251 B. WING £44 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

xayiD | SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
tac | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
i} DEFICIENCY)

PEACEFUL WAYS

|
Continued From page 18

took everything out of his pockets.”

-"I think he wanted me to come inside (facility). |
| was on the front porch because [client #1] was
running his mouth."

-Reported the incident to the Complaint Hot Line
and his care manager (Local Management
Entity/Managed Care Organization (LME/MCO)
Care Manager).

Interview on 7/1/25 with client #3 revealed:

-The Licensee/Direct Care Specialist said to FC
#2 "You will come willingly or forcefully”.

~"He (Licensee/Direct Care Specialist) handed his
keys to somebody like he was going to do
something (to FC #2).”

Interview on 7/11/25 with FC #2's LME/MCO Care
Manager revealed:

-During a phone call on 5/13/25 FC #2 stated he
was being mentally abused in the facility.

-"FC #2 said there was an incident going on and
[Licensee/Direct Care Specialist] had to
deescalate and had to get kids (clients) to move
to another area. [Licensee/Direct Care Specialist]
said, "You need to move or | will make you

| move.”

-Notified The Licensee/Direct Care Specialist of
the allegation on 5/13/25.

Interview on 7/9/25 with the Licensee/Direct Care
| Specialist revealed:

-Arrived at the facility and all of the clients were
on the front porch (date unknown).

-Was attempting to deescalate the situation and
get the clients to go inside.

-FC #2 "started cursing and said, ‘I don't want to
be here.”

=" told him you can go willingly or we can get the
police to make you go in.”

-FC #2 complied and the police were not called.
Division of Health Service Regulation
STATE FORM ae G6K611 If continuation sheet 19 of 67

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL013-251

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS:

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

Cc
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET

KANNAPOLIS, NC 28083

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

Continued From page 19

-The allegation was not investigated.
| -Was not suspended.
| -Was not reported to the HCPR.

-"FC #2] did report that someone was verbally
and mentally abusing him, but then when we got
on the CFT meeting he indicated that his words
were twisted that no one was verbally abusing
him."

-FC #2 did not name the person who he accused
of verbally abusing him

-Did not investigate.

~"There was nothing to investigate.”

-Did not suspend the Licensee/Direct Care
Specialist.

-Did not report the allegation to the HCPR.

27G .1704 Residential Tx. Child/Adol - Min.
Staffing

410A NCAC 27G .1704 MINIMUM STAFFING
REQUIREMENTS

(a) A qualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.

(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) two direct care staff shall be present for
one, two, three or four children or adolescents;

| (2) three direct care staff shall be present
for five, six, seven or eight children or
adolescents; and

(3) four direct care staff shall be present for
| nine, ten, eleven or twelve children or

| adolescents.

(c) The minimum number of direct care staff

Division of Health Service Regulation
STATE FORM

Interview on 7/8/25 with the Director/AP revealed:

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

V 296 27G .1704 Residential Tx.
Child/Adol - Min.
Staffing

+ Staffing schedules

were immediately adjusted
to ensure a minimum of
two staff are present at all
times when up to four
adolescents are in the
facility-July 19, 2025

+ A staffing schedule
review process has been
implemented to ensure
ratios are met before
weekly schedules are
finalized-QP and director
completed 7/19/25 and will
be ongoing

+ Supervisors will
complete random spot
checks during shifts to
confirm ratio compliance-
This started 7/25/25 and
will be ongoing

* Program Director:
oversight of staffing
schedules and compliance.
* QP/AP: monitoring

daily ratios and responding
to call-outs.

+ Program Director will
review staffing schedules
weekly to verify ratios are
met.

G6K611 If continuation sheet 20 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

c
MHLO013-251 B. WING ____H__ 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(xa) ID 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)

PEACEFUL WAYS

Continued From page 20

during child or adolescent sleep hours is as
follows:

(1) two direct care staff shall be present
and one shail be awake for one through four
children or adolescents;

(2) two direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

(3) three direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.

(d) In addition to the minimum number of direct
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.

(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they
are away from the facility in accordance with the
child or adolescent's individual strengths and
needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on observation, record review and

| interview, the facility failed to ensure the minimum
| staff ratio of two staff for up to 4 adolescents. The
| findings are:

Review on 6/27/25 of client #1's record revealed:
-Admission date of 4/11/25.

Division of Health Service Regulation
STATE FORM = G6K611 If continuation sheet 21 of 67

Division of Health Service Requlation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING

MHL013-251 B: ANG,

PRINTED: 07/28/2025
FORM APPROVED
COMPLETED

c
07/17/2025

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

518 EAST C STREET
PEACEFUL WAYS

KANNAPOLIS, NC 28083

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

Continued From page 21

-13 years old.

-Diagnoses of Conduct Disorder, Unspecified;
Trauma and Stressor Related Disorder; Attention
Deficit Hyperactivity Disorder, Combined
Presentation.

-Treatment Plan dated 10/28/24 and updated
5/7/25 and 6/5/25. Client #1 "does not currently
have access to any unsupervised community
areas.”

Review on 6/24/25 of FC #2's record revealed:
-Admission date of 3/21/25.

-17 years old.

-Discharge date of 6/23/25.

-Diagnoses of Post-Traumatic Stress Disorder,
Conduct Disorder.

-Treatment plan dated 9/4/24 and updated 5/2/25
and 6/2/25. FC #2 "does not currently have
access to any unsupervised community areas."

Review on 7/14/25 of client #3's record revealed:
-Admission date of 3/18/25.

-15 years old.

| -Diagnoses of Conduct Disorder with Limited

| Prosocial Behavior, Moderate; Attention Deficit
| Hyperactive Disorder- Inattentive Presentation;
Other Specified Trauma and Stressor Related
Disorder - Adjustment like Disorders with
Prolonged Duration.

-Treatment Plan dated 3/4/25 and updated
4/15/25, 5/20/25, and 6/24/25 did not include
information related to unsupervised time.

Review on 7/14/25 of client #4's record revealed:
-Admission date of 3/30/25.

-16 years old.

-Diagnoses of Reaction To Severe Stress,
Unspecified; Major Depressive Disorder.
-Treatment plan dated 1/14/25 and updated
4/21/25, 5/27/25, and 6/23/25. Client #4

Division of Health Service Regulation

STATE FORM 090

G6K611 if continuation sheet 22 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Re

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

c
07/17/2025

B, WING

MHL013-251

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER,

PEACEFUL WAYS

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES: 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 296 | Continued From page 22 V 296

"receives full-time supervision and does not have
unsupervised access to community settings at
this time."

Observation on 7/1/25 at a community camp from
42pm to 1:25pm revealed:

Clients #1, #3, and #4 present with no facility
staff.

| Interview on 7/1/25 with client #1 revealed:
-There was 1 to 2 staff on shift in the facility.

~"1 staff is there when we leave camp.”

-There was “always just" 1 staff on 3rd shift
(A1pm-7am).

-1 or 2 staff transported clients to and from camp.
"Sometimes 1 staff picks up and 2nd staff is
waiting at the house.”

Interview on 7/3/25 with former client #2
revealed:

-"There are supposed to be 2 staff but 95% of the
time there was only 1.”

-There was 1 staff on 3rd shift (11pm to 7am).
-"95% of the time there was 1 staff on 2nd shift

| (4pm to 11pm)." |
-Was transported to and from camp by 1 staff |
"95%" of the time. |
-There were no facility staff at camp.

Interview on 7/1/25 with client #3 revealed:
-Attended camp from 7:15am to 5pm or a little
later, Monday through Friday. No facility staff
were present.

-There were usually 2 staff at the group home,
sometimes less, but “not often.”

-"A lot of staff are quitting.”

-Sometimes 1 staff was in the facility for “a short
time” (could not be more specific) at shift change.

Interview on 7/1/25 with client #4 revealed:

Division of Health Service Regulation
STATE FORM 099 G6K611 If continuation sheet 23 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 8. WING £4444 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

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

PEACEFUL WAYS

| Continued From page 23

-There was "1 to 2” staff on shift in the facility.
-Attended camp from 7:30am to 4pm or Spm
Monday through Friday. No facility staff were
present.

-Was “usually” transported by 1 staff.

Interview on 7/2/25 with former staff #1 revealed:
-Had worked by herself "once ...or a few times.”
-Worked alone "overnight a couple of times from
41pm to 7 or 8am (during school). They (clients)
are pretty much asleep in their rooms.”

itis supposed to be 2 (staff) on alll shifts."

-"| believe | worked 2pm or 3pm to 11pm by

myself every now and then.”

Interview on 7/2/25 with staff #3 revealed:
-There was only 1 staff on 3rd shift (11pm to
7am).

-"[Staff #6] let me know that until | got hired in the
beginning of June (2025), she was the only staff
that worked 2nd shift.”

-Never worked an entire shift alone, but other
staff had.

-Went to pick up the clients from camp alone.

-"1 staff is a safety risk."

Interview on 7/7/25 with staff #4 revealed:
-Worked 11pm to 8am.

-Had worked 3rd shift alone.

-"We are understaffed right now."

"When | have had to do it (work) by myself we
| have had to try to get someone to come in.”

| "That shift (3rd) doesn't keep people.”
-Unable to tell the number of times he worked
| alone.
|

“Transported the clients to and from camp alone.

| Interview on 7/7/25 with staff #5 revealed:
-"There were a few shifts where | was alone just
in the crossing over (shift change).”
Division of Health Service Regulation
STATE FORM ane: G6K611 If continuation sheet 24 of 67

Division of Health Service Regulation

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

MHL013-251 BEWING

NAME OF PROVIDER OR SUPPLIER

518 EAST C STREET
PEACEFUL WAYS

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

(x4) 1D.
PREFIX
TAG

Continued From page 24

"| was there (at facility) 30 minutes maximum
alone."

Interview on 7/8/25 with the Qualified
Professional (QP) revealed:

-There were always 2 staff in the facility on 2nd

| shift (4pm or 5 pm to 11pm) and 3rd shift (11pm
to 8am).

-There are no staff working 1st shift (8am to 4pm
| or 5pm) Monday through Friday because the

| clients went to camp.

-Gamp staff provided supervision while the clients
were at camp.

-Did not know how the camp was staffed or the
training they received.

Interview on 7/8/25 with the Director/Associate
Professional (AP) revealed:

Clients attended camp from 8am until around
5pm.

-There were 2 staff on all shifts when clients were
in the facility.

~Sometimes, when staff called out of work, there
may have been only one staff until someone
could get there, no more than 30 minutes.

Interview on 7/9/25 with the Licensee/Direct Care
Specialist revealed:

-2 staff worked on all shifts.

~"If we have an emergency, [Director/AP] or [QP]
are no more than 30 minutes away, if we have a
call out."

-Clients were transported to camp by 2 staff.
-Camp counselors were responsible for
supervision when the clients were. at camp.

27G .0603 Incident Response Requirements

INCIDENT

| 10A NCAC 27G .0603

Division of Health Service Regulation
STATE FORM

(x2) MULTIPLE CONSTRUCTION
A. BUILDING:

KANNAPOLIS, NC 28083

G6K611

PRINTED: 07/28/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ff continuation sheet 25 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
07/17/2025

B. WING

MHL013-251
STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) 1D.
PREFIX
TAG

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

Continued From page 25

|
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS
(a) Category A and B providers shall develop and

| implement written policies governing their

response to level |, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals 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 andB
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
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:

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

V 366 27G .0603 Incident
Response Requirements
The facility immediately
submitted overdue preliminan
findings of fact for the cited
incident(s)- completed 7/14/2

Program Director reviewed all
open incident reports to ensu!
proper classification and timel
submission completed 7/14/2!

All staff will receive refresher
training on incident reporting
requirements within 10
business days-Completed
7/24/25

Supervisors and QPs will
conduct routine checks to
confirm timely submission of
findings to the LME.

Program Director: ensures
timely reporting and oversees
policy implementation.

Qualified Professional (QP):
investigates incidents and
prepares preliminary findings.

Quarterly audits of incident fil:
will be conducted to ensure
compliance with LME reportin:
standards.

Any deficiencies will be
addressed through corrective
coaching and retraining.

Division of Health Service Regulation
STATE FORM a G6K611

If continuation sheet 26 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 8. WING 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID 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)

PEACEFUL WAYS

ft

Continued From page 26

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an intemal
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 all 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;

(Cc) 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
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

Division of Health Service Regulation
STATE FORM ad G8K611 If continuation sheet 27 of 67

Division of Health Service Regulation

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

MHLO013-251

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
ABUILDING:

B. WING

COMPLETED

Cc
07/17/2025

NAME OF PROVIDER OR SUPPLIER

518 EAST C STREET

PEACEFUL WAYS

(xa) ID
PREFIX
TAG

V 366

KANNAPOLIS, NC 28083

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

Continued From page 27

(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 evidenced by:

Based on record review and interview, the facility
failed to implement written policies governing
their response to level Il incidents and failed to
issue written preliminary findings of facts within
five working days of the incident to the LME. The
findings are:

Review on 6/30/25 of the North Carolina Incident
Response Improvement System from
4/1/25-6/30/25 revealed:

-No report submitted for the allegation by FC #2
that the Licensee/Direct Care Specialist was
verbally abusive.

-No documentation of findings of the
investigation, corrective and preventative
measures, and person(s) responsible for

| implementation of corrective and preventative

measures.

Division of Health Service Regulation

STATE FORM

ID
PREFIX
TAG

V 366

G6K611

STREET ADDRESS, CITY, STATE, ZIP CODE

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

if continuation sheet 28 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: (<1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

c
MHL013-251 B. WING ________HkhH 07/17/2025

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

PI L Wi
EACEFUL WAYS KANNAPOLIS, NC 28083

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES iD 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) Tac (CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Continued From page 28 V 366

Interview on 7/3/25 with FC #2 revealed:
-"[Licensee/Direct Care Specialist] communicated
| threats to me and [client #3].”

~"He (Licensee/Direct Care Specialist) said (FC

| #2), "You are coming willingly or forcefully,’ and
took everything out of his pockets."

-"| think he wanted me to come inside (facility). |
was on the front porch because [client #1] was
running his mouth."

-Reported the incident to the Complaint Hot Line
and his care manager (Local Management
Entity/Managed Care Organization (LME/MCO)
Care Manager).

Interview on 7/1/25 with client #3 revealed:

-The Licensee/Direct Care Specialist said to FC
#2 "You will come willingly or forcefully.”

-"He (Licensee/Direct Care Specialist) handed his
keys to somebody like he was going to do

| something (to FC #2)."

| Interview on 7/11/25 with FC #2's LME/MCO Care
Manager revealed:

During a phone call on 5/13/25 FC #2 stated he

was being mentally abused in the facility.

"FC #2 said there was an incident going on and

[Licensee/Direct Care Specialist] had to

deescalate and had to get kids (clients) to move

to another area. [Licensee/Direct Care Specialist]

said, ‘You need to move or | will make you

move.”

-Notified The Licensee/Direct Care Specialist of

the allegation on 5/13/25.

Interview on 7/9/25 with the Licensee/Direct Care
Specialist revealed:

| -Arrived at the facility and all of the clients were
on the front porch (date unknown).

-Was attempting to deescalate the situation and
Division of Health Service Regulation
STATE FORM es09 GeKe11 Ifcontinuation sheet 29 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service R
‘STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA (42) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BULBNG COMPLETED

c
MHL013-251 8. WING 07/47/2025

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

PEACEFUL WAYS KANNAPOLIS, NC 28083

(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)

Continued From page 29

get the clients to go inside.

-FC #2 "started cursing and said, ‘| don’t want to
be here.”

-"I told him you can go willingly, or we can get the
police to make you go in.”

-FC #2 complied and the police were not called.
-The allegation was not investigated.

-Was not suspended.

Interview on 7/8/25 with the Director/AP revealed:
| -"[FC #2] did report that someone was verbally

| and mentally abusing him, but then when we got

| on the Child and Family Team meeting he

| indicated that his words were twisted, that no one
| was verbally abusing him.”

-FC #2 did not name the person who he accused
of verbally abusing him.

-Did not investigate the allegation.

"There was nothing to investigate.”

-Did not suspend the Director/Licensee or other
staff in relation to the allegation.

-Did not complete an investigation including
findings, corrective and preventative measures,
and person(s) responsible for implementation of
corrective and preventative measures.

27G .0604 Incident Reporting Requirements

410A 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!
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

Division of Health Service Regulation
STATE FORM oe G6K611 {f continuation sheet 30 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
07/17/2025

MHLO13-251 BP WING:

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(xa) ID SUMMARY STATEMENT OF DEFICIENCIES 1D | 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 | paTE

DEFICIENCY)

V 367 | Continued From page 30 V 367 V 367 27G .0604 Incident

services are provided within 72 hours of Reporting Requirements

| becoming aware of the incident. The report shall The facility immediately submitt |
be submitted on a form provided by the ; ; overdue preliminary findings of
Secretary. The report may be submitted via mail, fact for the cited incident(s)-
in person, facsimile or encrypted electronic completed 7/14/25 |
means. The report shail include the following |
information: . ‘ |

. . Program Director reviewed all |

1 mccaneinie laa eontactiand open incident reports to ensure
(2) client identification information; Peni eee Hind
(3) _ type of incident; sto P
(4) description of incident; . -
(8) status of the effort to determine the Tain will nadent aa ig
cause of the incident; and : pees :
(6) other individuals or authorities notified requirements within 10 business

days-Completed 7/24/25

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

Supervisors and QPs will conduc
routine checks to confirm timely

report recipients by the end of the next business submission of findings to the LN
day whenever: Program Director: ensures timel
(1) the provider has reason to believe that reporting and oversees policy
information provided in the report may be implementation.

erroneous, misleading or otherwise unreliable; or

(2) the provider obtains information Qualified Professional (QP):
required on the incident form that was previously investigates incidents and
unavailable. prepares preliminary findings.
(c) Category A and B providers shall submit,

upon request by the LME, other information Quarterly audits of incident files
obtained regarding the incident, including: will be conducted to ensure

(1) hospital records including confidential compliance with LME reporting
information; standards.

(2) reports by other authorities; and

(3) the provider's response to the incident. Any deficiencies will be

(d) Category A and B providers shall send a copy addressed through corrective

of all level III incident reports to the Division of coaching and retraining.

Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A

Division of Health Service Regulation
STATE FORM ome G6K611 If continuation sheet 31 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(
8. WING _______ 07/47/2025

MHL013-251

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

PEACEFUL WAYS.
“ KANNAPOLIS, NC 28083

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 08)
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 31 V 367

providers shall send a copy of all level Il!
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 |! or level III 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;
(5) the total number of level Il and level Ill
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 interview and record review, the facility
failed to report all Level II incident reports to the
Division of Health Service Regulation

STATE FORM sous, G6K611 If continuation sheet 32 of 67

PRINTED: 07/28/2025
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: ASBUIDING COMPLETED

c
MHL013-251 ——— 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

$< —___—_—
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | 1D 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) TAGS CROSS-REFERENCED TO THE APPROPRIATE
| DEFICIENCY)

PEACEFUL WAYS

V 367 | Continued From page 32 V 367

local management entity (LME)/Managed Care
Organization (MCO) responsible for the
catchment area where services are provided
within 72 hours of becoming aware of the
incident. The findings are:

Review on 6/30/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-No report submitted for the allegation by FC #2
that the Licensee/Direct Care Specialist was
verbally abusive.

Interview on 7/3/25 with FC #2 revealed:
~"[Licensee/Direct Care Specialist] communicated
threats to me and {client #3].”

-"He (Licensee/Direct Care Specialist) said (to
FC#2), "You are coming willingly or forcefully,’ and
took everything out of his pockets.”

~"I think he wanted me to come inside (facility). |
was on the front porch because [client #1] was
running his mouth."

-Reported the incident to the Complaint Hot Line
and his LME/MCO Care Manager.

Interview on 7/1/25 with client #3 revealed:

-The Licensee/Direct Care Specialist said to FC
#2 "You will come willingly.

~"He (Licensee/Direct Care Specialist) handed his
keys to somebody like he was going to do
something (to FC #2).”

Interview on 7/11/25 with FC #2's LME/MCO Care
Manager revealed:

-During a phone call on 5/13/25 FC #2 stated he
was being mentally abused in the facility.

-FC #2 "said there was an incident going on and
[Licensee/Direct Care Specialist] had to
deescalate and had to get kids (clients) to move
to another area. [Licensee/Direct Care Specialist]
said, ‘You need to move, or | will make you

Division of Health Service Regulation

STATE FORM om G6K611 If continuation sheet 33 of 67

PRINTED: 07/28/2025
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

c
MHLO13-254 8. WING: 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

ain | 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)

PEACEFUL WAYS

Continued From page 33

move.
-Notified the Licensee/Direct Care Specialist of
the allegation on 5/13/25.

Interview on 7/9/25 with the Licensee/Direct Care

Specialist revealed:

-Arrived at the facility and all of the clients were

on the front porch (date unknown).

_ -Was attempting to deescalate the situation and
get the clients to go inside.

-FC #2 "started cursing and said, ‘I don't want to

be here.”

-"| told him you can go willingly, or we can get the

police to make you go in.”

-FC #2 complied and the police were not called.

-The allegation of was not investigated.

-Was not suspended.

| Interview on 7/8/25 with the Director/AP revealed:
-"[FC #2] did report that someone was verbally

and mentally abusing him, but then when we got

on the CFT meeting he indicated that his words

were twisted that no one was verbally abusing

him."

-FC #2 did not name the person who he accused

of verbally abusing him.

-Was responsible for investigating allegations of

abuse.

-Did not investigate.

| “There was nothing to investigate.”

-Did not submit the incident within 72 hours of

becoming aware of the allegation.

-Did not determine the cause of the incident.

27D .0101(a-e) Client Rights - Policy on Rights

410A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS
(a) The governing body shall develop policy that

Division of Health Service Regulation
STATE FORM om G6K611 If continuation sheet 34 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

c
07/47/2025

B. WING

MHL013-251

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES 1D | PROVIDER'S PLAN OF CORRECTION 8)

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)

NAME OF PROVIDER OR SUPPLIER:

PEACEFUL WAYS

Vv500 Continued From page 34 v 500 V 500 27D .0101(a-e) Client
assures the implementation of G.S. 122C-59, Rights Policy on Rights
G.S. 122C-65, and G.S. 122C-66.

(b) The governing body shall develop and
implement policy to assure that:

(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are .
reported to the County Department of Social was properly submitted to DSS
Services as specified in G.S. 108A, Article 6 or completed 7/19/25

GS. 7A, Article 44; and - “ |
All staff will receive refresher

The Program Director reviewed
all current incident reports to
confirm that any allegation of
abuse, neglect, or exploitation

(2) procedures and safeguards are SU .
instituted in accordance with sound medical training on mandated reporting
practice when a medication that is known to laws and facility policy within 10
present serious risk to the client is prescribed. business days. (Completed
Particular attention shall be given to the use of 7/26/25) Training will emphasize:
neuroleptic medications.

| (c) In addition to those procedures prohibited in Duty to report immediately.
140A NCAC 27E .0102(1), the governing body of
each facility shall develop and implement policy Reporting procedures.

| that identifies:
(1) any restrictive intervention that is Documentation of reports.
prohibited from use within the facility; and
(2) _ ina 24-hour facility, the circumstances Program leadership will conduct
under which staff are prohibited from restricting quarterly policy reviews to
the rights of a client. ensure compliance with
(d) If the governing body allows the use of reporting requirements.

restrictive interventions or if, in a 24-hour facility,
the restrictions of client rights specified in G.S.

422C-62(b) and (d) are allowed, the policy shall Program Director: ensures

reporting compliance and

identify: I NT ecteat
(1) the permitted restrictive interventions or reviews all incidents. |
allowed restrictions; . .
(2) _ the individual responsible for informing Qualified Professional (QP) and |
the client; and Supervisors: responsible for

| (3) the due process procedures for an making immediate reports to

DSS and documenting
confirmation.

involuntary client who refuses the use of
restrictive interventions.

| (e) If restrictive interventions are allowed for use
within the facility, the governing body shall
develop and implement policy that assures

Division of Health Service Regulation
STATE FORM sae G6K611 tf continuation sheet 35 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 B. WING ______£_____H44H4H4H 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(xayio | 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)

PEACEFUL WAYS

—|—

| Continued From page 35

| compliance with Subchapter 27E, Section .0100,
which includes:

(1) the designation of an individual, who
has been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use of
restrictive interventions when the original order is
renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);

(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and

(3) the establishment of a process for
appeal for the resolution of any disagreement
over the planned use of a restrictive intervention.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all instances of alleged or
suspected abuse, neglect or exploitation were
reported to the county department of social
services (DSS). The findings are:

Finding #1:

Review on 6/27/25 of client #1's record revealed:
-Admission date of 4/11/25.

-13 years old.

-Diagnoses of Conduct Disorder, Unspecified;
Trauma and Stressor Related Disorder; Attention
Deficit Hyperactivity Disorder, Combined
Presentation.

Review on 7/9/25 of staff #3's personnel file
revealed:
| Direct Care Specialist.
Division of Health Service Regulation
STATE FORM 899 G6K611 if continuation sheet 36 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service R

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X14) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

c
07/17/2025

WWWNG

MHL013-251

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

WAY:
PEACEFUL WAYS KANNAPOLIS, NC 28083

(xayiD | ‘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
Tac | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 36
-Hire date of 6/4/25.

-Evidence Based Protective Interventions
(EBPI)-Base Plus 6/4/25.

Refer to V132 Finding #1 details regarding the
altercation between Former Staff (FS) #1 and
Client #1. Staff #3 video taped the altercation
and neglected to to protect Client #1 by not
physically intervening during the altercation.
Finding #2 details, FC#2 alleged the
| Director/Licensee/Direct communicated threats to
him.

Review on 6/30/25 of the North Carolina Incident
Response Improvement System from
4/1/25-6/30/25 revealed:
~"On June 26, 2025, at approximately 8:52 PM,
the Director (Director/Associate Professional)
was notified by staff (#3) that an altercation had
occurred between staff (former staff (FS) #1) and
client (#1) during evening chores. Staff (#3)
reported that law enforcement had been called.
The Qualified Professional (QP) arrived on site |
within 30 minutes, and the Director
(Director/Associate Professional) followed shortly
after. Police were already present. Upon arrival,
client (#1) was seated on the porch with visible
surface scratches to the chest, which did not
require medical attention. Staff (FS #1) was in the
yard and reported no injuries. [Client #1] stated
he was washing dishes when staff (FS #1) began
rushing him. When he didn't comply, [FS #1]
removed the dish rag from him and sat down.
[Client #1] retrieved the rag and resumed
cleaning. [FS #1] returned to the kitchen, yelling.
[Client #1] sprayed her with water, which
escalated into physical contact, including pushing
and exchanging blows. The conflict moved
outdoors before they were separated ...Staff (#3)
was present during the incident but did not
Division of Health Service Regulation
STATE FORM ees G6K611 If continuation sheet 37 of 67

PRINTED: 07/28/2025
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: AcBUDING: COMPLETED
c
MHL013-251 Be WING 07/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
PEACEFULIWAYS 518 EAST C STREET
KANNAPOLIS, NC 28083
(xa) 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)
V 500 | Continued From page 37 Vv 500 |

intervene and left the scene when police arrived.
Both client and staff (FS #1 and Client #1 were
assessed for injury by QP (Qualified Professional)
and Director (Director/Associate Professional
(AP)).”

Interview on 7/8/25 with the Director/AP revealed: |
-Arrived at the facility on 6/26/25 and staff #3 had
already left.

-Started the investigation immediately.

-"| don't want to say it was abuse but it was
wrong.”

-Staff #3 recorded a video, but did not share it
with facility staff.

-Staff #3 had not responded to attempts to reach
her.

~"[Staff #3] indicated that she quit." |
-"| was going to officially terminate her.” |
-"| haven't been able to substantiate whether or |
not she intervened."

-"She (staff #3) won't be back, but | haven't
Officially given her anything (termination notice)
because | haven't gotten her side of the story."
-Did not complete the investigation of neglect by
staff #3 for failing to protect client #1 from abuse.
-Did not report staff #3 to DSS

Interview with the Licensee/Direct Care
Specialist:

| -Staff #3 "claims she didn't see anything and

| “claims she tried to deescalate.”

"The police said [staff #3] had video. How are
you deescalating when you are recording?”
-Staff #3 was "let go" because of neglect.

| -Staff #3 was in the area (of the incident) but
started recording and failed to deescalate or
intervene when the verbal escalation started.
-"You are supposed fo intervene.”

-An investigation of neglect by staff #3 for failing
to protect client #1 from abuse was not

Division of Health Service Regulation

STATE FORM baa G6K611 If continuation sheet 38 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service R
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

Cc
MHL013-251 SWING 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(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)

PEACEFUL WAYS

Continued From page 38

completed.
-Staff #3 was not reported to DSS.

Finding #2:

Review on 6/30/25 of the Licensee/Direct Care
Specialist's personnel file revealed:

| -Hire date of 6/28/21.

| -EBPI-Base Plus 2/3/25.

Review on 6/24/25 of former client (FC) #2's
record revealed:

-Admission date of 3/21/25.

-17 years old.

-Discharge date of 6/23/25.

-Diagnoses of Post-Traumatic Stress Disorder,
Conduct Disorder.

Interview on 7/3/25 with FC #2 revealed:
-"[Licensee/Direct Care Specialist] communicated
threats to me and [client #3].”

-"He (Licensee/Direct Care Specialist) said (to FC
#2), ‘You are coming willingly or forcefully,’ and
took everything out of his pockets."

"| think he wanted me to come inside (facility). |
was on the front porch because [client #1] was
running his mouth.”

-Reported the incident to the Complaint Hot Line
and his care manager (Local Management
Entity/Managed Care Organization (LME/MCO))
Care Manager.

Interview on 7/11/25 with FC #2's LME/MCO Care
Manager revealed:

-During a phone call on 5/13/25 FC #2 stated he
was being mentally abused in the facility.

-"FC #2 said there was an incident going on and
[Licensee/Direct Care Specialist] had to
deescalate and had to get kids (clients) to move
Division of Health Service Regulation

STATE FORM = G6K611 Hf continuation sheet 39 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (x4) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(x3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A.BUILDING:

c
07/17/2025

B. WING

MHLO13-251

STREET ADDRESS, CITY, STATE, ZIP CODE.

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(xayiD | 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)

V500| Continued From page 39 Vv 500

to another area. [Licensee/Direct Care Specialist]
said, 'You need to move or | will make you
move.”

-Notified the Licensee/Direct Care Specialist of
the allegation on 5/13/25. |

Interview on 7/9/25 with the Licensee/Direct Care
Specialist revealed:

-Arrived at the facility and all of the clients were

| on the front porch (date unknown).

-Was attempting to deescalate the situation and
get the clients to go inside.

| -FC #2 "started cursing and said, ‘| don't want to
| be here.”

-"| told him you can go willingly or we can get the
police to make you go in."

-FC #2 complied and the police were not called.
-The allegation was not investigated.

-Was not suspended.

-Allegation was not reported to Dss.

Interview on 7/8/25 with the Director/AP revealed:
-"[FC #2] did report that someone was verbally
and mentally abusing him, but then when we got
on the Child and Family Team meeting he

| indicated that his words were twisted that no one
| was verbally abusing him."

-FC #2 did not name the person who he accused
of verbally abusing him.

-Did not investigate.

-"There was nothing to investigate.”

-Did not report the allegation to DSS.

27D .0304 Client Rights - Harm, Abuse, Neglect

410A NCAC 27D .0304 PROTECTION FROM
HARM, ABUSE, NEGLECT OR EXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance

Division of Health Service Regulation
STATE FORM eee G6K611 If continuation sheet 40 of 67

Division of Health Service Ri

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(x4) 1D
PREFIX
TAG

Vv 512

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

gulation

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-251

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 07/28/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET

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

Continued From page 40

with G.S. 122C-66.

(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10A NCAC
27C .0102 of this Chapter.

(c) Goods or services shall not be sold to or
purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation by an employee of Paragraphs
(a) through (d) of this Rule shall be grounds for
dismissal of the employee.

This Rule is not met as evidenced by:

Based on record review and interview, 1 of 4
staff (#3) neglected to protect 1 of 3 current
clients (#1) from abuse. The findings are:

Review on 6/27/25 of client #1's record revealed:
-Admission date of 4/11/25.

-13 years old.

-Diagnoses of Conduct Disorder, Unspecified;
Trauma and Stressor Related Disorder; Attention
Deficit Hyperactivity Disorder, Combined
Presentation.

Review on 7/9/25 of staff #3's personnel file
revealed:
-Direct Care Specialist.

Division of Health Service Regulation

STATE FORM

KANNAPOLIS, NC 28083

PREFIX
TAG

Vv 512

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

DEFICIENCY)

V 512 27D .0304 Client
Rights - Harm, Abuse,
Neglect

The staff member identified in
the citation was immediately

removed from client care dutie
pending investigation 6/26/25

The affected client was
assessed to ensure safety and
well-being, and supportive
services were provided 6/26/2
and 6/27/25

The incident was reported to
DSS, HCPR, and other requirec
authorities in compliance with
mandated reporting
requirements 6/26/25 and
7/14/25

All staff will complete refreshe
training on abuse/neglect
prevention, mandatory
reporting, and client protectio
responsibilities within 10
business days. Completed
7/26/25

The facility will reinforce its
policy requiring staff to
intervene and protect clients
immediately when witnessing
suspecting abuse or neglect.

Supervisors will increase
random, unannounced

observations on shifts to
monitor staff interactions with
clients. Started 7/19/25 and is

G6K611

CROSS-REFERENCED TO THE APPROPRIATE

Cc
07/17/2025

(x5)
COMPLETE.
DATE

Kf continuation sheet 41 of 67

Division of Health Service Ri
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL013-251

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

PEACEFUL WAYS

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

Continued From page 41

-Hire date of 6/4/25.
-Evidence Based Protective Interventions
(EBPI)-Base Plus 6/4/25.

Review on 6/30/25 of the North Carolina Incident
Response Improvement System (IRIS) from
4/1/25-6/30/25 revealed:

-"On June 26, 2025, at approximately 8:52 PM,

| the Director (Director/Associate Professional

| (AP)) was notified by staff (#3) that an altercation
had occurred between staff (former staff (FS) #1)
and client (#1) during evening chores. Staff (#3)
reported that law enforcement had been called.

| The Qualified Professional (QP) arrived on site
within 30 minutes, and the Director (Director/AP)
followed shortly after. Police were already
present. Upon arrival, client (#1) was seated on
the porch with visible surface scratches to the
chest, which did not require medical attention.
Staff (FS #1) was in the yard and reported no
injuries. [Client #1] stated he was washing dishes
when staff (FS #1) began rushing him. When he
didn't comply, [ FS #1] removed the dish rag from
him and sat down. [Client #1] retrieved the rag
and resumed cleaning. [FS #1] retumed to the
kitchen, yelling. [Client #1] sprayed her with
water, which escalated into physical contact,
including pushing and exchanging blows. The
conflict moved outdoors before they were

| separated ...Staff (#3) was present during the

| incident but did not intervene and left the scene
when police arrived. Both client (#1) and staff (FS
#1) were assessed for injury by QP and Director
TAP."

Review on 7/2/25 of video #1 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 28 seconds long.

-In the living room, FS #1 was struggling with
client #1 on the sofa and was pulling client #1's
Division of Health Service Regulation

STATE FORM

PROVIDER'S PLAN OF CORRECTION

DEFICIENCY)

V 512 27D .0304 Client
Rights - Harm, Abuse,
Neglect

Program Director: ensures
staff accountability and
reporting compliance.

Qualified Professional (QP):
provides staff training and
direct monitoring of
implementation.

The Program Director will
review all incident reports
within 24 hours to verify
staff responded
appropriately to protect
clients.

ae G6K611

PRINTED: 07/28/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
07/17/2025

(EACH CORRECTIVE ACTION SHOULD BE
(CROSS-REFERENCED TO THE APPROPRIATE

If continuation sheet 42 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES: (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AEDS COMPLETED

c
MHL013-251 B. WING _________ 07/47/2025

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

PEACEFUL WAYS:
KANNAPOLIS, NC 28083
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID 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)
——————EEE
——
V512| Continued From page 42 Vv 512
hair.
| -Both of FS #1's hands were holding client #1's
hair.

-FS #1 was on top of client #1.

-Staff #3 was yelling at client #1 to stop and
telling him "Police are coming and they are going
to take your a’*s to jail."

-Client #1 said, "Tell her to get the f**k off me.”
-Staff #3 said, "If she gets off of you what ...
(unintelligible).”

-FS #1 got off the sofa, continued to grip and pull
client #1’s hair with both hands.

-Staff #3 said, "What benefit?” and yelled, "Stop,
oh my God."

-Client #1 and FS #1 continued to struggle with
one another until the video ended.

- Staff #3 did not attempt to physically intervene.

Review on 7/2/25 of video #2 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 33 seconds long.

-FS #1 was on the floor pulling client #1's hair
with both hands.

-FS #1 and client #1 continued to struggle with
one another as FS #1 wrapped her legs around
Client #1's legs as she was pulling his hair.
-Client #1 slapped FS #1 on the right shoulder
and FS #1 released Client #1's hair.

-FS#1 then kicked client #1's head while they
were still both on the floor.

-An unknown person yelled, "You are on your own
[client #1]."

Client #1 got to his feet and moved away from
FS #1.

-FS #1 grabbed client #1 ankle when client #1
attempted to kicked her.

him.

-Staff #3 said,"[Client #1], s**t, stop, stop."

-Client #1 grabbed a football and threatened to
throw it at FS #1's head.

Division of Health Service Regulation

STATE FORM seam GeK611 Ifcontinuation sheet 43 of 67

PRINTED: 07/28/2025
FORM APPROVED

gulation

(X14) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

Division of Health Service R
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A.BUILDING:

c
07/17/2025

WING.

MHL013-251

STREET ADDRESS, CITY, STATE, ZIP CODE.

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 6)
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)

a

Continued From page 43 Vv 512

_Staff #3 did not attempt to physically intervene.
-The video ended.

Interview on 7/1/25 with client #1 revealed:
-On 6/26/25 FS #1 took away the dish rag while
he was doing dishes.

-FS #1 "pushed me" and “I pushed her back."
_FS #1 “hit me in the stomach or chest so |
started hitting her back."

~"Had a few scratches on my chest and one on
my arm and forgot were the rest of the scratches
were.’
- FS #1 "pulled out chunks of my hair in little balls
everywhere.”

-Staff #3 did not physically intervene to stop FS
#1. |

Interview on 7/1/25 with client #3 revealed:

-On 6/26/25, client #1 was cleaning his dishes.

| -Heard arguing and saw FS #1 “snatch" the dish

towel.

-FS #1 went to her seat and client #1 tried to

"grab her.” |

-FS #1 "pushed" client #1.

Client #1 and FS #1 "started tussling-grabbed

each other pulling hair, kicking.”

-They were fighting, wrestling on the floor for

about 8 minutes. "Somehow it ended up

outside.”

-Staff #3 called the law enforcement and |

recorded some of the altercation.

-Staff #3 "stayed for 3 minutes to talk to the cops
and pulled off (left facility) and said, she quit.”

Interview on 7/1/25 with client #4 revealed:

-On 6/26/25 there was an argument and a
“physical altercation" between client #1 and FS
#1.

-Staff #3 called the police and "filmed the whole
thing.”

Division of Health Service Regulation
STATE FORM om, G6K611 If continuation sheet 44 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 a 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID 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)

PEACEFUL WAYS:

Continued From page 44

-Staff #3 “told them (FS #1 and Client #1) to
stop."

Interview on 7/2/25 with FS #1 revealed:

| -On 6/26/25 client #1 was washing dishes and

| playing in the sink when she told him to go to bed.
- She and client #1 argued back and forth about
turning off the water until client #1 "pushed and
shoved" her.

- She grabbed client #1 by his hair “trying to
restrain him.”

- They continued to struggle with one another and
ended up outside on the facility's porch.

-Staff #3 did not help.

- Staff #3 recorded the incident and called the
police.

- When the police arrived, staff #3 explained her
part and "left (facility).”

- Staff #3 would not give out any information (to
the police), "like her address."

Interview on 7/2/25 with staff #3 revealed:

-On 6/26/25, Client #1 was washing dishes when
FS #1 "was asking [client #1] to get ready for bed.
He told her no."

-FS #1 and Client #1 "started going back and
forth” verbally.

"| told him (client #1) to do dishes and her (FS
#1) to calm down.”

- When Client #1 continued to play in the water,

| FS #1 turned the water off.

| - Client #1 sprayed FS #1 with the water and said,
"Do you want to have a water fight."

- FS #1 pushed client #1 and they both started
"pushing and shoving.”

-"[Client #1] was choking [FS #1]. | wasn't
recording at this time.”

~"I called the police.”

- FS #1 and Client #1 "continued to fight like
strangers.”
Division of Health Service Regulation
STATE FORM e009 GeK611 If continuation sheet 45 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 BENING. 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(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)

PEACEFUL WAYS

Continued From page 45

_ FS #1 was “pulling client #1's hair. Some of it
came out."

- Client #1 grabbed a football and threw it at FS
#1. “I didn't want to trigger him, so | stopped
recording.”

- Client #1 threw the football at FS #1's face and
they "started fighting again."

-"Lopened up the door (facility) and heard
sirens."

-"[Client #1] grabbed a stick and attempted to hit
| (FS #1), and they tussled with the branch (stick)."
-"| told them to put the branch down, and they
did."

- After the police arrived, she let the officers know
that the Director/AP and Licensee/Direct Care
Specialist were on their way and then "| left
(facility).”

-"| didn't want to help or assist when she (FS #1)
is fighting. It would look like we were ganging up
on him (client #1)."

-"As soon as they (FS #1 and client #1) were
tussling, | jumped up and told them to calm down.
Nobody listened so, | called 911."

~"Later on, | pulled out my phone to record.”

-"| didn't get (record) the beginning and didn't get
the part on the porch.”

interview on 7/8/25 with the Director/AP revealed:
- Arrived at the facility on 6/26/25 and staff #3 had
already left.

- Started the investigation into FS #1's actions

| during the incident immediately and concluded

| that FS #1 "did not follow de-escalation protocol
putting a client (#1) at risk."

-"| haven't been able to substantiate whether or

| not she (Staff #3) intervened."

- Staff #3 recorded a video but did not share it
with facility staff.

- Staff #3 had not responded to attempts to reach
her.

Division of Health Service Regulation

STATE FORM Load G6KE11 Hf continuation sheet 46 of 67

PRINTED: 07/28/2025
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 BOLDIN: COMPLETED
ie

MHL013-251 B. WING ______H 4H 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID 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)

PEACEFUL WAYS

V512| Continued From page 46

- "[Staff #3] indicated that she quit.”

- "| was going to officially terminate her.”

-"She (FS #1) won't be back, but | haven't
officially given her anything (termination notice)
because I haven't gotten her side of the story.”

Interview 7/9/25 with the Licensee/Direct Care
Specialist revealed:

-FS #1 did not "respond appropriately" during the
incident with client #1 on 6/26/25.

-FS #1 was terminated for lack of de-escalation
techniques and the wrong use of EBP!.”

-Client #1 had some superficial scratches and
hair pulled out. Client #1 “declined” medical
treatment.

-Staff #3 "claims she didn't see anything and
"claims she tried to deescalate."

"The police said [staff #3] had video. How are
you deescalating when you are recording?"
-Staff #3 was "let go" because of neglect.
-Staff #3 was in the area (of the incident) but
started recording and failed to deescalate or
intervene when the verbal escalation started.
-"You are supposed to intervene.”

Review on 7/14/25 of the Plan of Protection dated
7/14/25 written by the Director/AP revealed:
"What immediate action will the facility take to
ensure the safety of the consumers in your care?
| -The QP or a designated staff member will
conduct informal check-ins with each consumer
within the next 24 hours to ensure they feel safe,
address any concems, and identify needs for
emotional support. This will be documented in the
consumer's chart.

-All direct care staff, QPs, and supervisors will
complete refresher training on abuse, neglect,
and exploitation within 10 business days.

-The Director/AP will update the IRIS report to
include all staff implicated in the abuse incident.
Division of Health Service Regulation

STATE FORM oe GeK611 V continuation sheet 47 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation

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

(x3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

Cc
07/17/2025

MHLO013-251

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS
KANNAPOLIS, NC 28083
(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)

Continued From page 47

-If specific staff are involved in or suspected of
contributing to the neglect they will be removed
from direct consumer contact while the matter is
investigated. Staff will be adjusted using available
| relief or PRN (as needed) staff to maintain

| adequate supervision. Termination of employee

| involved (termination completed July 7th).

| -Starting immediately, brief team huddles at the
start and end of each shift will be used to review
safety concems, ensure all assigned duties are
understood, and allow staff to raise any issues
impacting consumer care.

-The House Manager or QP will increase
walkthroughs for the next two weeks to observe
staff-consumer interactions, verify proper
supervision, and provide immediate coaching if |
concerns arise.

-Describe your plans to make sure the above
happens.

-The QP will document each consumer check-in
in their chart. Any issues identified will be
communicated to the clinical team and addressed
within 48 hours. The Facility Director will review
documentation to ensure completion.

-The resubmission of the IRIS report/Health Case
(Care) Registry will be reflective of the additional
staff being implicated

| -The QP or Director will schedule training
sessions and circulate attendance rosters. Topics
will include definitions of abuse/neglect,
mandatory reporting procedures, and prevention
strategies. Attendance will be documented, and
copies of materials and sign-in sheets will be
stored in staff records for verification.

Any future incidents will trigger immediate staffing
adjustments per policy.

-The "Home Base" app (scheduling software) will
be used to log start- and end-of-shift huddles. |
The QP will set daily reminders and provide
space within the app for staff to record any
Division of Health Service Regulation

STATE FORM sal G6K611 If continuation sheet 48 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

c
07/17/2025

MHLO013-251

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES iD 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 DATE
DEFICIENCY)

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

Continued From page 48

concerns. Entries will be monitored weekly.

-A standardized "Walkthrough Observation Log”
will be used to record staff-consumer interactions,
supervision practices, and any coaching provided.
Walkthroughs will occur throughout the week for

| the next two weeks. Logs will be reviewed by the
Facility Director for compliance."

Review on 7/15/25 of the amended Plan of
Protection dated 7/15/25 written by the
Director/AP revealed:

"What immediate action will the facility take to |
ensure the safety of the consumers in your care?
-All direct care staff, QPs, and supervisors will
complete refresher training on abuse, neglect,
and exploitation by July 24th, 2025.

-The Director will update the June 26, 2025, IRIS
report to include all staff implicated in the abuse
incident. The report was updated July 14, 2025 to
| add the staff member.

-If specific staff are involved in or suspected of
contributing to the neglect in the June 26, 2025

| incident, they will be removed from direct
consumer contact while the matter is
investigated. Staff will be adjusted using available
relief or PRN staff to maintain adequate

| supervision. Staff involved in the incident were
suspended the same day as the incident June 26,
2025. Termination of employee involved

| (termination completed July 7th)."

Client #1 was diagnosed with Conduct Disorder,
Unspecified; Trauma and Stressor Related
Disorder, and Attention Deficit Hyperactivity
Disorder, Combined Presentation. On June 26,
2025, FS #1 and Client #1 were involved in a
physical altercation in which FS #1 pulled Client
#1's hair and kicked him in his head causing
scratches to Client #1's chest and arm. Staff #3
neglected client #1 by not intervening to stop FS
Division of Health Service Regulation

STATE FORM 6899 G6K611 if continuation sheet 49 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
07/17/2025

B. WING

MHL013-251

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS KANNAPOLIS, NC 28083
a
(xa) ID SUMMARY STATEMENT OF DEFICIENCIES iD 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 DATE

DEFICIENCY)

+

Continued From page 49 V 512 V 536 27E .0107 Client Rights

#1 from abusing client #1, rather, she video - Training on Alt to Rest.
recorded the incident, made comments that Int
further escalated the crisis, and did not respond Former staff #1 is no longer
to client #1's calls for help. This deficiency employed at the facility
| constitutes a Type A1 rule violation for serious terminated 7/7/25 |

neglect and must be corrected within 23 days.

The clients served by this staff

V 536) 27E .0107 Client Rights - Training on Alt to Rest. V 536 were reviewed to ensure there

Int. were no unresolved concerns
related to the use of interventio

10A NCAC 27E .0107. TRAINING ON done 7/19/25 and 7/20/25
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS | 2s All current staff will receive
(a) Facilities shall implement policies and refresher training on alternative
Practices that emphasize the use of alternatives to restrictive interventions, de-
{0 resivictive interventions. ; escalation techniques, trauma-
(b) Prior to providing services to people with informed care, and behavioral

disabilities, staff including service providers, . saps
employees, students or volunteers, shall support strategies within 10
demonstrate competence by successfully business days. This was
completing training in communication skills and completed 19f; 25 team huddle
other strategies for creating an environment in and video on training

which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data

The facility will implement a
competency checklist to be
completed by the Qualified
Professional (QP) for all staff
upon hire, after refresher

gathered. trainings, and annually to verify
(d) The training shall be competency-based, knowledge and skills in
include measurable learning objectives, alternatives to restrictive
measurable testing (written and by observation of interventions to be implemente
behavior) on those objectives and measurable by 9/15/25
methods to determine passing or failing the Program Director: ensures
course. training completion and policy
(e) Formal refresher training must be completed oversight.
by each service provider periodically (minimum
annually). Qualified Professional (QP):
(f) Content of the training that the service conducts competency

Division of Health Service Regulation

STATE FORM 099 cexelt roficiency. Ieontinuation sheet 50 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
MHL013-251 et es 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(xa) 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)

PEACEFUL WAYS

Continued From page 50

provider wishes to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

| (2) recognizing and interpreting human

| behavior;

(3) recognizing the effect of internal and
external stressors that may affect people with

| disabilities;

| (4) strategies for building positive
relationships with persons with disabilities;

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for
escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(9) Positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

(h) Service providers shall maintain
documentation of initial and refresher training for
| at least three years.

(1) Documentation shall include:

(A) who participated in the training and the
outcomes (pass/fail);

(B) when and where they attended; and
(C) instructor's name;

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.

Division of Health Service Regulation
STATE FORM aaa G6K611 If continuation sheet 51 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
07/17/2025

B. WING

MHL013-251

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
WAYS
PEACEFUL: s KANNAPOLIS, NC 28083

(xa) 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) Tacs CROSS-REFERENCED TO THE APPROPRIATE | DATE

DEFICIENCY)

Continued From page 51

(i) instructor Qualifications and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the
| need for restrictive interventions.

(2) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.

(3) The training shall be |
competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.

(5) Acceptable instructor training programs
| shail include but are not limited to presentation of:

(A) understanding the adult learner;

(B) methods for teaching content of the

course;

(C) methods for evaluating trainee

performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

(8) Trainers shall complete a refresher
instructor training at least every two years.

(j) Service providers shall maintain

Division of Health Service Regulation
STATE FORM om G6K611 'f continuation sheet 52 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: (1) PROVIDER/SUPPLIER/CLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

Cc
07/17/2025

MHLO013-254

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

PEACEFUL WAYS

(xa) 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)

Continued From page 52

documentation of initial and refresher instructor
training for at least three years.

(1) Documentation shall include:

who participated in the training and the
outcomes (pass/fail);

s

(B) when and where attended; and
| (C) instructor's name.
(2) The Division of MH/DD/SAS may

request and review this documentation any time.
(k) Qualifications of Coaches:

(1) Coaches shall meet all preparation
requirements as a trainer.

(2) Coaches shall teach at least three times
the course which is being coached.

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

(1) Documentation shall be the same preparation
as for trainers.

This Rule is not met as evidenced by:
Based on record review and interviews, the
facility failed to ensure 1 of 5 audited staff (former
staff (FS) #1) demonstrated competence in
alternatives to restrictive interventions. The
findings are:

Review on 6/30/24 of FS #1's personnel file
revealed:

-Direct Care Specialist.
-Hire date of 4/9/25.
~Termination date of 7/7/25.
Division of Health Service Regulation
STATE FORM ee G6K611 I continuation sheet 3 of 67

PRINTED: 07/28/2025

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

c
MHL013-251 8. WING ____________—_ 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID 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)

PEACEFUL WAYS.

Continued From page 53

-Evidence Based Protective Interventions
(EBPI)-Base Plus 4/16/25.

Review on 6/30/25 of the North Carolina Incident
Response Improvement System (IRIS) from
4/1/25-6/30/25 revealed:

~"On June 26, 2025, at approximately 8:52 PM,

| the Director (Director/Associate Professional (AP)
was notified by staff (#3) that an altercation had

| occurred between staff (former staff (FS) #1) and
client (#1) during evening chores. Staff (#3)
reported that law enforcement had been called.
The Qualified Professional (QP) arrived on site

| within 30 minutes, and the Director (Director/AP)
| followed shortly after. Police were already
present. Upon arrival, client (#1) was seated on
the porch with visible surface scratches to the
chest, which did not require medical attention.
Staff (FS #1) was in the yard and reported no
injuries. [Client #1] stated he was washing dishes
when staff (FS #1) began rushing him. When he
didn't comply, [ FS #1] removed the dish rag from
him and sat down. [Client #1] retrieved the rag
and resumed cleaning. [FS #1] returned to the
kitchen, yelling. [Client #1] sprayed her with
water, which escalated into physical contact,
including pushing and exchanging blows. The
conflict moved outdoors before they were
separated ...Staff (#3) was present during the
incident but did not intervene and left the scene
when police arrived. Both client (#1) and staff (FS.
#1) were assessed for injury by OP and Director
JAP."

Review on 7/2/25 of video #1 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 28 seconds long.

-In the living room, FS #1 was struggling with
client #1 on the sofa and was pulling client #1's
hair.

Division of Health Service Regulation
STATE FORM 0599 G6KE11 If continuation sheet 54 of 67

PRINTED: 07/28/2025

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: COMPLETED
A.BUILDING:
Cc
MHL013-251 8. WING __££_£_____ 07/17/2025
NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
PEACEFUL WAYS.
KANNAPOLIS, NC 28083
(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)
V 536} Continued From page 54 V 536

-Both of FS #1's hands were holding client #1's
hair.

-FS #1 was on top of client #1.

-Staff #3 was yelling at client #1 to stop and
telling him "Police are coming and they are going
to take your a’s to jail.”

-Client #1 said, “Tell her to get the f**k off me.”
-Staff #3 said, "If she gets off of you what ...
(unintelligible)."

-FS #1 got off the sofa, continued to grip and pull
client #1's hair with both hands.

-Staff #3 said, "What benefit?” and yelled, "Stop,
oh my God.”

-Client #1 and FS #1 continued to struggle with
one another until the video ended.

- Staff #3 did not attempt to physically intervene.

Review on 7/2/25 of video #2 recorded by staff #3
of the incident on 6/26/25 revealed:

-Video was 33 seconds long.

-FS #1 was on the floor pulling client #1's hair

| with both hands.

| -FS #1 and client #1 continued to struggle with
one another as FS #1 wrapped her legs around
Client #1's legs as she was pulling his hair.
-Client #1 slapped FS #1 on the right shoulder

| and FS #1 released Client #1's hair.

-FS#1 then kicked client #1's head while they
were still both on the floor.

-An unknown person yelled, "You are on your own
[client #1]."

-Client #1 got to his feet and moved away from
FS #1.

-FS #1 grabbed client #1's ankle when client #1
attempted to kick her. |
-Staff #3 said,"[Client #1], s**t, stop, stop.”
-Client #1 grabbed a football and threatened to
throw it at FS #1's head.

-Staff #3 did not attempt to physically intervene.
-The video ended.

Division of Health Service Regulation

STATE FORM bia GeK611 'f continuation sheet 55 of 67

PRINTED: 07/28/2025
FORM APPROVED

Division of Health Service Requlation
STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
MHL013-251 B. WING _______ 07/17/2025

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

KANNAPOLIS, NC 28083

aio | SUMMARY STATEMENT OF DEFICIENCIES ] ID | 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)

PEACEFUL WAYS:

Continued From page 55 V 536

Review on 7/9/25 of the facility's termination letter
to FS #1 dated 7/7/25 and written by the
Director/Associate Professional (AP) revealed:
~"This letter serves as formal notice of the
termination of your employment with Peaceful
Ways Residential Services, effective
immediately.”

-"Following a recent incident involving an

| altercation between yourself and a client residing
| in our facility, an internal investigation was
conducted. The findings of this investigation
determined that you were the aggressor in the
situation and failed to adhere to the agency's
established protocols, including approved
de-escalation techniques. Your actions directly
violated our safety policies and placed the client
at significant risk."

Interview on 7/1/25 with client #1 revealed:

-On 6/26/25 FS #1 took away the dish rag while
he was doing dishes.

-FS #1 "pushed me” and "I pushed her back.”
-FS #1 “hit me in the stomach or chest so |
started hitting her back.”

-"Had a few scratches on my chest and one on
my arm and forgot were the rest of the scratches
were."

- FS #1 "pulled out chunks of my hair in little balls
everywhere.”

-Staff #3 did not physically intervene to stop FS
#1,

Interview on 7/1/25 with client #3 revealed:

-On 6/26/25, client #1 was cleaning his dishes.
-Heard arguing and saw FS #1 “snatch” the dish
| towel.

-FS #1 went to her seat and client #1 tried to
“grab her.”

-FS #1 “pushed” client #1.

Division of Health Service Regulation

STATE FORM e809 GeK61i Hfcontinuation sheet 56 of 67

PRINTED: 07/28/2025

FORM APPROVED

Division of Heatth Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED

c
MHL013-251 8. WING _____—_£_—_—_— 07/47/2025

NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDERS PLAN OF CORRECTION
Paepe TEACH 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)

PEACEFUL WAYS

Continued From page 56

-Client #1 and FS #1 "started tussling-grabbed
each other pulling hair, kicking."

-They were fighting, wrestling on the floor for
about 8 minutes. "Somehow it ended up
outside.”

-Staff #3 called the law enforcement and
recorded some of the altercation.

-Staff #3 "stayed for 3 minutes to talk to the cops
and pulled off (left facility) and said, she quit."

Interview on 7/1/25 with client #4 revealed:

-On 6/26/25 there was an argument and a
"physical altercation” between client #1 and FS
#1,

-Staff #3 called the police and "filmed the whole
thing."

-Staff #3 “told them (FS #1 and Client #1) to
stop."

Interview on 7/2/25 with FS #1 revealed:

-On 6/26/25 client #1 was washing dishes and
playing in the sink when she told him to go to bed.
- She and client #1 argued back and forth about
turning off the water until client #1 "pushed and
shoved" her.

- She grabbed client #1 by his hair "trying to
restrain him."

- They continued to struggle with one another and
ended up outside on the facility's porch.

-Staff #3 did not help.

- Staff #3 recorded the incident and called the
police.

- When the police arrived, staff #3 explained her
part and "left (facility)."

- Staff #3 would not give out any information (to
the police), "like her address.”

Interview on 7/2/25 with staff #3 revealed:

-On 6/26/25, Client #1 was washing dishes when
FS #1 "was asking [client #1] to get ready for bed.
Division of Health Service Regulation

STATE FORM bad G6KE11 {continuation sheet 57 of 67

PRINTED: 07/28/2025

FORM APPROVED.

Division of Health Service Requlation
‘STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BOULDING: COMPLETED

c
MHLO13-251 B. WING 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID | 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
i DEFICIENCY)

PEACEFUL WAYS.

Continued From page 57

He told her no."

-FS #1 and Client #1 "started going back and
forth" verbally.

~"I told him (client #1) to do dishes and her (FS
#1) to calm down.”

- When Client #1 continued to play in the water,
FS #1 tumed the water off.

- Client #1 sprayed FS #1 with the water and said,
"Do you want to have a water fight."

- FS #1 pushed client #1 and they both started
“pushing and shoving.”

-"[Client #1] was choking [FS #1]. I wasn't

| recording at this time.”

-"| called the police."

- FS #1 and Client #1 "continued to fight like
strangers.”

- FS #1 was "pulling client #1's hair. Some of it
came out.”

- Client #1 grabbed a football and threw it at FS
#1. "I didn't want to trigger him, so | stopped
recording."

- Client #1 threw the football at FS #1's face and
they "started fighting again.”

-"l opened up the door (facility) and heard
sirens.”

- "[Client #1] grabbed a stick and attempted to hit
(FS #1), and they tussled with the branch (stick)."
-"| told them to put the branch down, and they
did."

- After the police arrived, she let the officers know
that the Director/AP and Licensee/Direct Care
Specialist were on their way and then "I left
(facility)."

-"| didn't want to help or assist when she (FS #1)
is fighting. It would look like we were ganging up
on him (client #1).”

-"As soon as they (FS #1 and client #1) were
tussling, | jumped up and told them to calm down.
Nobody listened so, | called 911."

-"Later on, | pulled out my phone to record.”
Division of Health Service Regulation

STATE FORM La GOK611 If continuation sheet 58 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 es 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID 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)

PEACEFUL WAYS

Continued From page 58

-"| didn't get (record) the beginning and didn't get
the part on the porch."

Interview on 7/8/25 with the Director/AP revealed:
- Arrived at the facility on 6/26/25 and staff #3 had
already left.

- Started the investigation into FS #1's actions
during the incident immediately and concluded
that FS #1 "did not follow de-escalation protocol
putting a client (#1) at risk."

- "| haven't been able to substantiate whether or
not she (Staff #3) intervened.”

~ Staff #3 recorded a video but did not share it
with facility staff.

- Staff #3 had not responded to attempts to reach
her.

- "[Staff #3] indicated that she quit.”

- "| was going to officially terminate her."

-"She (FS #1) won't be back, but | haven't
Officially given her anything (termination notice)
because | haven't gotten her side of the story.”

Interview with the Licensee/Direct Care Specialist
revealed:

-FS #1 did not "respond appropriately” during the
incident with client #1 on 6/26/25.

-"She (FS #1) was terminated for lack of
de-escalation techniques and the wrong use of
EBPI."

27E .0108 Client Rights - Training in Sec Rest &
ITO

10A NCAC 27E .0108 TRAINING IN
SECLUSION, PHYSICAL RESTRAINT AND
ISOLATION TIME-OUT

(a) Seclusion, physical restraint and isolation
time-out may be employed only by staff who have
been trained and have demonstrated

Division of Health Service Regulation
STATE FORM aaiael GBK611 if continuation sheet 59 of 67

PRINTED: 07/28/2025
FORM APPROVED.
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc

B. WING 07/17/2025

MHLO013-251

STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) ID
PREFIX
TAG

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

Continued From page 59

competence in the proper use of and alternatives
to these procedures. Facilities shall ensure that
staff authorized to employ and terminate these
procedures are retrained and have demonstrated

| competence at feast annually.
| (b) Prior to providing direct care to people with

disabilities whose treatment/habilitation plan
includes restrictive interventions, staff including
service providers, employees, students or
volunteers shall complete training in the use of
seclusion, physical restraint and isolation time-out
and shail not use these interventions until the
training is completed and competence is
demonstrated.

(c) Apre-requisite for taking this training is

| demonstrating competence by completion of

training in preventing, reducing and eliminating
the need for restrictive interventions.

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.

(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually).

(f) Content of the training that the service
provider plans to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.

(g) Acceptable training programs shall include,
but are not limited to, presentation of:

(1) refresher information on alternatives to
the use of restrictive interventions;

(2) guidelines on when to intervene
(understanding imminent danger to self and
others);

(3) emphasis on safety and respect for the

Division of Health Service Regulation

STATE FORM

10
PREFIX
TAG

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

V 537 27E .0108 Client
Rights - Training in Sec Rest
&

\f6lmer staff #1 is no longer
employed at the facility
terminated 7/7/25

Staff #3 resigned the night c
the incident on 6/26/25

Staff #4 also resigned on
7/20/25.

All current staff will complet
updated in person training i
seclusion, physical restraint,
and isolation time-out,
including demonstration ani
observed testing, within 30
days.by 9/15/25

AP/QP will conduct quarterl
observation checks to verify
continued staff competency
in safe and appropriate use
of restrictive interventions.

Program Director: ensures
training compliance and
policy enforcement.

Qualified Professional (QP)

and Certified Trainer: condu
training, observe skills, and

document competency.

G6K611

If continuation sheet 60 of 67

PRINTED: 07/28/2025
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED

A. BUILDING

c
BeWING 07/17/2025

MHL013-251

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES: 10 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)

V 537 | Continued From page 60 V 537

| rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

interventions which include continuous
assessment and monitoring of the physical and
psychological well-being of the client and the safe
use of restraint throughout the duration of the
restrictive intervention;

(6) prohibited procedures;

(7) debriefing strategies, including their
importance and purpose; and

(8) documentation methods/procedures.

(h) Service providers shall maintain
documentation of initial and refresher training for
at least three years.

(1) Documentation shall include:

(A) who participated in the training and the
outcomes (pass/fail);

(B) when and where they attended; and
(C) instructor's name.
| (2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program

| aimed at preventing, reducing and eliminating the
need for restrictive interventions.

| (2) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.

(3) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.

(4) The training shall be

Division of Health Service Regulation
STATE FORM oes G6K611 If continuation sheet 61 of 67

PRINTED: 07/28/2025
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

c
MHLO013-251 SS SE aS 07/17/2025

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

PEACEFUL WAYS
KANNAPOLIS, NC 28083

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID 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) | Tac CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

V 537 Continued From page 61 V 537

competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

(5) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (j)(6) of this Rule.

(6) Acceptable instructor training programs
shall include, but not be limited to, presentation
of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) evaluation of trainee performance; and
(D) documentation procedures.

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use
of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in |
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.

(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.

(11) Trainers shall complete a refresher
instructor training at least every two years.

(k) Service providers shall maintain
documentation of initial and refresher instructor
training for at least three years.

(1) Documentation shall include:

(A) who participated in the training and the

outcome (pass/fail);
ee ___L
Division of Health Service Regulation

STATE FORM oe G6K611 If continuation sheet 62 of 67

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(4) ID
PREFIX |
TAG

PRINTED: 07/28/2025
FORM APPROVED

MHLO13-251

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A BUILDING:

518 EAST C STREET

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

Continued From page 62

(B) when and where they attended; and
(C) instructor's name.

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.
(1) Qualifications of Coaches:

(1) Coaches shali meet all preparation
requirements as a trainer.

(2) Coaches shall teach at least three
times, the course which is being coached.

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

(m) Documentation shall be the same
preparation as for trainers.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure annual training, including
measurable testing by observation of behavior, in
seclusion, physical restraint and isolation time-out
was completed for 3 of 6 audited staff (former
staff (FS) #1, staff #3, and staff #4) and failed to
ensure that staff demonstrated competency in
restrictive interventions for 2 of 6 audited staff (FS
#1 and staff #3). The findings are:

Review on 6/30/24 of FS #1's personnel file
revealed:

-Direct Care Specialist.

-Hire date of 4/9/25.

-Termination date of 7/7/25.

-Evidence Based Protective Interventions
(EBPI)-Base Plus 4/16/25.

Review on 7/9/25 of staff #3's personnel file

Division of Health Service Regulation

STATE FORM

COMPLETED

c
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

KANNAPOLIS, NC 28083

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

G6K611 if continuation sheet 63 of 67

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(x4) ID

PREFIX |

TAG

MHLO13-251

PRINTED: 07/28/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING:

B. WING

518 EAST C STREET

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

KANNAPOLIS, NC 28083

COMPLETED

Cc
07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

| Continued From page 63

revealed:

| -Direct Care Specialist.
-Hire date of 6/4/25.
-EBPI-Base Plus 6/4/25.

Review on 7/9/25 of staff #4's personnel file
revealed:

-Direct Care Specialist.

-Hire date of 3/10/25.

-EBPI-Base Plus 3/12/25.

Interview on 7/2/25 with FS #1 revealed:

-Was trained on EBPI on Zoom.

-Was not trained physically on restraints or
blocks.

-There was not an in-person training for EBPI.
-Had been taught to “let them (clients) have their
moments and ignore them.”

| Interview on 7/2/25 with staff #3 revealed:

| -EBPI training was completed on zoom.

-"| was the only one in that class. It was me and
a guy talking.”

-Was not trained physically on restraints or
blocks.

-"It did concern me that it was a zoom link
(without an in-person class). These boys (clients)
| charge at us and try to hurt us. We were not
properly trained.”

Interview on 7/7/25 with staff #4 revealed:

-The de-escalation portion of EBPI training was
virtual via Zoom.

| -"We didn't get to do the in person (restrictive
interventions) yet. We are waiting for the
instructor."

-"My restraint experience was from a prior group
home."

Interview on 7/11/25 with the EBPI trainer

Division of Health Service Regulation
STATE FORM

a G6K611

If continuation sheet 64 of 67

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

PEACEFUL WAYS

(X4) ID
PREFIX
TAG

IDENTIFICATION NUMBER:

MHL013-251

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

518 EAST C STREET

KANNAPOLIS, NC 28083

PRINTED: 07/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
07/17/2025

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

|

Continued From page 64

revealed:
-Prevention portion of the training completed

| virtually through Zoom.

-The prevention portion of the training includes

| demonstrations by the instructor of blocks and
restraints.

-Conducted an in-person restrictive intervention
training teach the physical techniques.

-The in-person restrictive intervention training is
usually completed the day after the Zoom training
or within the next week.

-The EBPI-Base Plus certificate indicated that the

| trainee received both the preventative and

restrictive portions of the training.

Interview on 7/14/25 with the Director/Associate
Professional revealed:

-EBPI training should include an in-person
component to demonstrate and practice
Testrictive intervention techniques.

-Did not have staff sign-in sheets.

27F .0102 Client Rights - Living Environment

10A NCAG 27F .0102 LIVING

| ENVIRONMENT

(a) Each client shall be provided:

(1) an atmosphere conducive to
uninterrupted sleep during scheduled sleeping
hours, consistent with the types of services being
provided and the type of clients being served: and
(2) accessible areas for personal privacy,
for at feast limited periods of time, unless
determined inappropriate by the treatment or
habilitation team.

(b) Each client shall be free to suitably decorate
his room, or his portion of a multi-resident room,
with respect to choice, normalization principles,
and with respect for the physical structure. Any

Division of Health Service Regulation
STATE FORM

1D
PREFIX
TAG

G6K611

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

If continuation sheet 65 of 67

PRINTED: 07/28/2025
FORM APPROVED.
gulation

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

Division of Health Service R

‘STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c

MHL013-254 07/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

518 EAST C STREET
KANNAPOLIS, NC 28083

NAME OF PROVIDER OR SUPPLIER,

PEACEFUL WAYS

(4) 1D
PREFIX
TAG

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

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

V 539

Continued From page 65

restrictions on this freedom shall be carried out in
accordance with governing body policy.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure there was an atmosphere
conductive to uninterrupted sleep during
scheduled sleeping hours and accessible areas
for personal privacy affecting 1 of 4 audited
clients former client (FC) #1). The findings are:

Observation on 7/7/25 in the facility at
approximately 1pm revealed:

-Bathroom with storage shelves was assessable
by walking through FC #1's bedroom.

-The door to the bathroom/storage room was
locked.

Interview on 7/3/25 with FC #1 revealed:

-"My room was the one with the closet/staff
bathroom (staff bathroom/storage closet). Meds
(medications) were stored there.”

-"Sometimes staff brought clients into the closet
(staff bathroom/storage closet) to give meds."

-"| told staff not to let them (clients) in my room. It
is a safety issue."

-"Staff came in to use (through FC #1's bedroom
to the staff bathroom/storage closet) the
bathroom, even at night. They did not knock."

Interview on 7/2/25 with staff #2 revealed:

| -Medications were stored in the "staff

bathroom/storage closet.”

| -Had to go through FC #2's room to get to the

staff bathroom/storage closet.

Interview on 7/7/7 with staff #4 revealed:

Division of Health Service Regulation

STATE FORM

G6K611

V 539 27F .0102 Client
Rights - Living
Environment

Staff were immediately
directed to cease using the
storage area in the client's
room 7/19/25

No clients have been placed
in this room since client
discharge which was before
this complaint

Construction plans have bee
initiated to create a new
entryway into the storage
area to-eliminate staff access
to the storage space via clier
space. Completion is
scheduled for 9/15/25.

Staff Communicaiton was
reinforced on maintaining a
safe, private, and restful
environment for all clients
and construction plans and
future entry were discussed.

Program Director: oversees
construction and policy
enforcement.

QP/AP monitor daily staff
compliance with room use
policies.

If continuation sheet 66 of 67

PRINTED: 07/28/2025
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

c
MHL013-251 B.WING 07/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
518 EAST C STREET
KANNAPOLIS, NC 28083

(x4) ID 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)

PEACEFUL WAYS

Continued From page 66

-It was necessary to go through FC #2's room to
get to the staff bathroom/storage closet.
-Clients were not allowed to use that bathroom
(staff bathroom/storage closet).

-Utilized the staff bathroom/storage closet when
working 3rd shift (11pm to 8am).

-"| make a noise and let him (FC #2) know | am
coming.”

-"| try to be quiet if he is sleeping.”

Interview on 7/7/25 with staff #5 revealed:

-Had to go through FC #2's bedroom to get to the
staff bathroom/storage closet.

-"We were supposed to knock on door and ask to
go through to the bathroom.”

-"He (FC #2) never said no (we could not go
through is room)."

Interview on 7/8/25 with the Qualified
Professional revealed:

-Utilized the bathroom accessed through FC #2's
bedroom as the staff bathroom/storage closet."
-FC didn't have "any issues" with staff going
through his room to get to the staff
bathroom/storage closet.

Interview on 7/8/25 with the Director/Associate
Professional revealed:

-The staff bathroom/storage closet was used to
store anything that needed to be locked up such
as meds, sharps, and chemicals.

-Clients were not allowed in the staff
bathroom/storage closet.

-Staff only utilized the staff bathroom/storage
closet when FC #2 was awake.

Division of Health Service Regulation
STATE FORM me G6K611 if continuation sheet 87 of 67

document_type: Plan of Correction