state: NC

facility_name: Transcending Heights  LLC

summary: Statement of Deficiency - MHLCS Complaint and Follow-up

raw_content:
Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

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
facility or to a patient or client.

e. Fraud against a health care facility or against

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

STATE FORM

6808 OEHS511

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
A complaint and follow up survey was completed
on 6/6/25. The complaint was unsubstantiated
(intake #NC00230200). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 6 and has a current
census of 4. The survey sample consisted of
audits of 4 current clients, 3 former clients.
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

(X6) DATE

If continuation sheet 1 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

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 that the North Carolina Health
Care Personnel Registry (HCPR) was notified of
all allegations against health care personnel
within 24 hours, failed to make every effort to
protect clients from harm while an investigation
was in progress, and failed to report the results of
the investigation within five working days of the
initial notification. The findings are:

Review on 5/22/25 of "Notification of CPS (Child
Protective Services) Involvement" dated 4/1/25
revealed:

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

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

-Admitted 10/24/24.

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

-Discharged 3/27/25.

-Discharge Summary:

-"Discharge Disposition-Since her (FC #1) arrival

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

If continuation sheet 2 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

(10/24/24), [FC #1] has exhibited extreme
behaviors on a daily basis to include sexual
inappropriateness with peers (other clients), staff,
teachers, and school administrators,
manipulation, staff splitting, compulsive lying,
false claims of sexual assault, property
destruction, aggression, profanity,
noncompliance, multiple AWOL (absent without
leave) attempts, physical assaults, verbal abuse,
spitting, staff intimidation, etc.

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

-Course of Treatment ...Since admission
(10/24/24) to level three services, the resident
has shown constant regression to include
instances of property destruction, verbal and
physical aggression, attention-seeking behaviors,
false allegation of sexual assault [van driver,
school officials, residential staff (facility staff)],
AWOL attempts, suicidal ideations, and self-harm
attempts resulting in multiple hospitalizations ..."

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

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

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

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 3 V 132

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

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

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

-He interviewed facility staff, current clients, FC
#1 and FC #1's DSS Social Worker/Legal
Guardian (SW/LG) and concluded, based on FC
#1 report and reports from staff and clients in the
facility, that there was a lack of evidence to
substantiate the report of abuse.

Interview on 6/2/25 with FC #1 revealed:
-She had been at the facility for about 2 years and
liked it there.

-Did not have any concerns with staff.

-Had been in the hospital (psychiatric) since her
IVC and discharge from the facility on 3/27/25.
-"Just want to say | was obsess (obsessed). | like
her (Staff #4) a lot. | did appreciate her, had love
for her in a sense; my love for her is gone; not, |
mean, not all the way. | regret what | did and said;
| was weird toward her, called her a b****h, | really
regret that; wasn't weird, but | was clingy; | got
attached too fast."

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

-Was touched by Staff #4 a week before she was
discharged on 3/27/25, when she and Staff #4
had fallen asleep on the couch together and were
caught by the HM/QP#2, "they [HM/QP#2] were
walking in (facility)...and they (HM/QP#2) said ‘get
up' and she (Staff #4) said 'no, lay back down’,
and | was confused about who | should listen to; |

Division of Health Service Regulation
STATE FORM

6808 OEHS511

If continuation sheet 4 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

took [Staff #4]'s side because | care about her
more. | feel like [HM/QP#2] knew (about the
touching)...she (HM/QP#2) thought | was in love
with her (Staff #4)."

-Was scared to tell anyone because she didn't
think she would be believed.

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

-FC #1 had left the facility often, police had to go
get her, and was not gone more than 30 minutes.
-FC #1 liked lying about Staff #4 and would get
angry with Staff #4 when she didn't give FC#1 the
attention FC #1 wanted.

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

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 4 V 132

If continuation sheet 5 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

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

-If FC #1 liked someone, "she (FC #1) would
always try to take things further, like asking staff
out and when she doesn't ' t get an answer she
will lie...she (FC #1) doesn't ' t like rejection and
would make things up."

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

-FC #1 liked hugging and staff was helping FC #1
to work on respecting personal space. "We
(staff) just dapped (fist bump) her up instead of
hugging" because of how long FC #1 would try to
extend a hug.

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

Interview on 6/3/25 with Staff #3 revealed:

-FC #1 had made "multiple allegations".

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

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

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

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

-Was named as the perpetrator of abuse by FC
#1 and was made aware of FC #1's allegation of
abuse (kissing and attempted touching) when the
4/1/25 report came from DSS and the DSS Social
Worker Investigator arrived at the facility in April
2025 (dates unknown).

-Had never had any intimate or inappropriate

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 5 V 132

If continuation sheet 6 of 27

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/18/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
06/06/2025

contact with FC #1.

-"I'm not sure if they (facility) contacted or made
any reports to anything (IRIS, HCPR)."

-"The facility did an investigation (April 2025).
Once it (FC #1's 4/1/25 allegation of Staff #4
kissing and attempting to touch her) was brought
up, it was discussed. [Home Manager
(HM/QP#2)] and | were contacted by [Human
Resource/Compliance Consultant (HR/CC)] and
we discussed house rules, but | don't know what
transpired outside of myself, like with other staff
members, | can only speak about what happened
with me."

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

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

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

-She and QP#1 were responsible for incident
reporting.

-Was aware of FC #1's 4/1/25 allegation of Staff
#4 kissing and attempting to touch FC #1 and
was made aware by DSS on 4/1/25.

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

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

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

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

-Staff had redirected and had addressed in

Division of Health Service Regulation
STATE FORM

6809

OEHS511

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 6 V 132

If continuation sheet 7 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

treatment team meetings that FC #1 had issues
respecting boundaries, behavior, profanity and
inappropriate comments to staff like, ‘hey, you're
cute.’

-Was aware of FC #1's accusation of sexual
assault by van driver that resulted in loss of
transportation resource.

-Had not made an HCPR report and was not
aware if there had been an HCPR report made to
address FC #1's 4/1/25 allegation of Staff #4
kissing and attempting to touch FC #1.

-There was no facility investigation and Staff #4
was not removed from the schedule because FC
#1 had been discharged.

-QP #1 was responsible for HCPR reporting and
HR/CC was responsible for internal investigation.

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

-Was hired 3/15/25.

-Was responsible for completing IRIS reports and
HCPR reports.

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

-"| wasn't there when it (Staff #4 allegedly kissing
and attempting to touch FC #1) happened."

-Was aware that FC #1 had accused (date
unknown) the van driver of touching her and the
facility lost their use of transportation resource,
"...we (staff) talked to her (FC #1) about lying on
people when she gets angry."

-Was not responsible for the HCPR report
because FC #1 had already been discharged
from the facility on 3/27/25.

-Did not submit report to HCPR once she was

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 7 V 132

If continuation sheet 8 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

made aware sometime during the week of
3/31/25 to 4/4/25 (exact date unknown) of FC
#1's 4/1/25 allegation of Staff #4 kissing and
attempting to touch FC #1.

-Was not sure whether there was a report to
HCPR to address FC #1's allegation of Staff #4
kissing and attempting to touch FC #1.

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

-Contracted consultant.

-Was made aware (April 2025) by DSS SW.
Investigator of the 4/1/25 report of FC #1's
allegation of Staff #4 kissing and attempting to
touch FC #1.

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

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

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

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

-No IRIS and HCPR reports were made because
the facility only learned of the DSS report in April
2025 and FC #1 had already been discharged
and was no longer a client in the facility

-Staff #4 was not removed from the facility
schedule pending an investigation.

-Was responsible for internal investigation of any
allegations.

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

This deficiency constitutes a re-cited deficiency

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 8 V 132

If continuation sheet 9 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-240

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/18/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
06/06/2025

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

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response 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 I.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service

Division of Health Service Regulation
STATE FORM

6809

OEHS511

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 9 V 132
and must be corrected within 30 days.
V 366} 27G .0603 Incident Response Requirements V 366

If continuation sheet 10 of 27

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

CONCORD,

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2025

A. BUILDING:

NC 28027

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
06/06/2025

or while the client is on the provider's premises.
The policies shall require the provider to respond

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete 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;

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

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

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 10 V 366

If continuation sheet 11 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;
(C) the provider agency with responsibility

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and
(F) any other authorities required by law.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to implement written policies
governing their response to level |, II and III
incidents. The findings are:

Review on 5/22/25 of "Notification of CPS (Child
Protective Services) Involvement" dated 4/1/25
revealed:

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 11 V 366

If continuation sheet 12 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

her, child pushed away..."

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

-Admitted 10/24/24.

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

-Discharged 3/27/25.

-Discharge Summary, completed 3/27/25 by
Former Qualified Professional (FQP):
-"Discharge Disposition-Since her (FC #1) arrival
(10/24/24), [FC#1] has exhibited extreme
behaviors on a daily basis to include sexual
inappropriateness with peers, staff, teachers, and
school administrators, manipulation, staff
splitting, compulsive lying, false claims of sexual
assault, property destruction, aggression,
profanity, noncompliance, multiple AWOL (absent
without leave) attempts, physical assaults, verbal
abuse, spitting, staff intimidation, etc. To ensure
safety for both [FC #1] and others in the home,
the Resident was discharged from the facility
because the resident was physically and verbally
aggressive, displayed property destruction,
attempted to go awol, and made multiple
self-harm attempts and threats."

-"Course of Treatment ...Since admission
(10/24/24) to level three services, the resident
has shown constant regression to include
instances of property destruction, verbal and
physical aggression, attention-seeking behaviors,
false allegation of sexual assault [van driver,
school officials, residential staff (facility staff)],
AWOL attempts, suicidal ideations, and self-harm
attempts resulting in multiple hospitalizations ..."
-"Discharge Plan-The resident was IVC'd
(involuntarily committed), and [Facility] will
support the transition to a higher level of care
and/or alternate placement."

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 12 V 366

If continuation sheet 13 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-240

A. BUILDING:

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD,

NC 28027

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
06/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-"Discharge Outcome-Discharged-Regression."

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

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

Review on 6/5/25 of the Facility Police Calls for
Service Report 1/1/25 through 6/5/25 revealed:
-1/5/25, 16:10 (4:10pm), Domestic Assault,
[Former Staff #7 (FS#7)], W911, Notes: no signs
of suicidal ideology, group home employees are
going to work on obtaining IVC paperwork on the
juvenile (FC #1). They (facility) were advised that
we (law enforcement) are not able to transport
her (FC #1) without the IVC paperwork from the
mags (magistrate) office; Caller is member of the
group home staff (FS #7); No Weapons; 17 YOA
(years of age) F/M; mixed female subj (subject)
has beat up all of the staff. has spit on the caller
(FS #7) and made threats to other reside
(clients)."

-1/24/25 13:51 (1:51pm), Child Abuse Complaint,
Self (facility), Notes: Not on scene. Intake report.
-1/24/25, "18:46 (6:46pm), Missing Person [Staff
#1], E911, Notes: Upon arrival | spoke with the
house manager (HM/QP#2), [HM/QP#2] who
stated at approximate 6:15 pm [Former Client #3
(FC#3)] left the residence (facility)...While on site
taking notes for the 81 report [FC #3]. She
(FC#3) she needed to get away for the moment
and went to [fast food restaurant]. [FC#3] stated
she would not leave the residence (facility) again
and would remain in side; Arrived back home
(facility)...19:25 (7:25pm); [FC#3] WF (white
female) blonde and blk (black) hair, blk jacket

Division of Health Service Regulation

STATE FORM

6809

OEHS511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 13 V 366

If continuation sheet 14 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-240

A. BUILDING:

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD,

NC 28027

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
06/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

-2/8/25, 15:43 (3:43pm), Missing Person Child,
[FS#8], W911, Notes: Juvenile (FC #3)left in the
care of para professional [Staff #9], who stated
she will be transporting the juvenile to [County] for
further evaluation and placement, [FC #3];
Notified 2/8/25, 15:48 (3:48pm) twrds (towards)
shopping center black hoodie, navy blue baby
yoda pajama pants, [sneaker brand] shoes blk
and gry (grey) bag, and red crossbody purse left
on foot client ran away, 15 year old white female
[FC#3]."

-3/21/25, "22:57 (10:27pm), Check Welfare, [Staff
#6], Notes:...One female juvenile (FC #1);
Prisoner in custody, 23:01 (11:01pm); Back at the
home (facility) but needs transport her to hospital;
heavy set female short Mohawk hair style [FC #1]
17 yo (year old); Female jumped out the window,
subject have a 73 episode (mental distress)."
-3/25/25, "19:15 (7:15pm), General Disturbance
[QP#1], Notes: | located [FC #1] on the ramp of
[interstate highway]. She voluntarily got in my car
and returned to the group home where | turned
her over to staff. [FC #1] state she was not going
to hurt herself and just wanted to leave for a
while. She stated she would remain at the group
home for the evening (19:59, 7:59pm); On
[interstate highway]...female flagged me
down...walking...caller lost sight, caller in a gray
[make/model]; history of self harm trying to walk
in between cars short haircut heavy set female
green shorts and purple jacket...female trying to
run off group home no known weapons [FC #1]
17 yo female."

-4/2/25, "9:45am, Child Abuse Complaint, Self;
Notes: DSS (Department of Social Services)
report; 3/27/25 18:56 (6:56pm) Mental
Commitment, Notes: [FC #1]..."

Division of Health Service Regulation

STATE FORM

6809

OEHS511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 14 V 366

If continuation sheet 15 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

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

-There was no documentation of level |, Il, or Ill
incidents.

-No documentation of internal investigation.

-No documentation that the facility attended to the
health and safety needs of the individuals
involved in the incident, determined the cause of
the incident, developed and implemented
corrective measures, developed and
implemented measures to prevent similar
incidents, and assigned person(s) to be
responsible for implementation of the corrections
and preventive measures.

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

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

-Was made aware on 4/1/25 by DSS of the
allegation by FC #1 that Staff #4 kissed and had
attempted to touch FC #1.

-Had reported escalation of client behaviors
beginning around 3/21/25 and had reported her
concerns (March 2025) about FC #1's
inappropriate behaviors to the facility.

-Was not sure if facility had documented incidents
of FC #1's behaviors. "I know what was
discussed (staff) was that she was on her 30
days (behavior contract) and her behavior on a
whole was being monitored."

-"We (facility) keep an incident reporting log in the
facility. | believe these things (FC #1's behaviors)
were documented."

-Had never written an incident report.

-"From my understanding, she (FQP) completed

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 15 V 366

If continuation sheet 16 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

the incident reports...| provided her any
information she may need."

-Was not sure if there were any incidents
documented.

-Was not aware if a report was completed in IRIS
for FC #1's 4/1/25 allegation of Staff #4 kissing
and attempting to touch FC #1.

-She had not been taken off the facility schedule
pending an internal investigation.

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

Interview on 6/2/25 with the Home
Manager/QP#2 revealed:

-Qualified Professional (QP).

-She and QP #1 were responsible for reporting
incidents.

-Knew that FC #1 had issues respecting
boundaries, behavior, profanity and inappropriate
comments to staff (‘hey, you're cute’) that had
been redirected by staff and addressed in team
meetings.

-An IRIS report had been submitted for the
3/27/25 incident resulting in FC #1 being
involuntarily committed.

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

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

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

-Hired on 3/15/25.

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 16 V 366

If continuation sheet 17 of 27

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/18/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
06/06/2025

contract.

-"We (facility) lost our transportation because [FC
#1] accused him (van driver) of touching her
(March 2025) and we (staff) talked to her about
lying on people when she gets angry. We were
able to get transportation (van) back after [FC
#1]'s discharge."

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

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

-Was responsible for completing IRIS reports.
-Did not submit incident report in IRIS and did not
report to HCPR once she was made aware of the
abuse (Staff #4 kissing and attempting to touch
FC #1) allegation, "I didn't do one (incident
report). I'm confused why would | do an incident
report or report it ( 4/1/25 allegation) if she (FC
#1) said it (allegation) after she was discharged?"
-"| did an incident report when the client was
IVCed (involuntarily committed) 3/27 (2025), it's in
the system, | completed it in IRIS."

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

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

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

-Contracted consultant.

-Responsible for overseeing reporting of
incidents.

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

Division of Health Service Regulation
STATE FORM

6809

OEHS511

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366] Continued From page 17 V 366

If continuation sheet 18 of 27

Division of Health Service Regulation

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

MHL013-240

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2025

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
06/06/2025

documented for incidents of FC #1's behavior as
described in the 3/27/25 discharge summary.
.-Did not submit incident reports and was not
responsible for submitting IRIS reports.

-Was not aware of the 4/1/25 report of FC #1's
allegation of Staff #4 kissing and attempting to
touch FC #1 until DSS came to the facility in April
2025.

-The QPs were responsible for IRIS reports, "...1
would receive a copy to keep track and make
sure the follow through is taken care of (IRIS and
HCPR completed). | provide them (facility) with
the information, then follow up to make sure it is
done."

-Acknowledged she did not complete a thorough
investigation to attend to the health and safety
needs of the individuals involved in the incident,
determine the cause of the incident, develop and
implement corrective measures, develop and
implement measures to prevent similar incidents,
and assign person(s) to be responsible for
implementation of the corrections and preventive
measures.

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

V 367| 27G .0604 Incident Reporting Requirements V 367

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

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III

Division of Health Service Regulation
STATE FORM 6899 OEH511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 18 V 366
-Was not aware of police reports (1/1/25 through
6/5/25).
-Was not aware if level 1, Il, Il reports were

If continuation sheet 19 of 27

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 06/18/2025

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
06/06/2025

incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the
cause of the incident; and

(6) other individuals or authorities notified

or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 19 V 367

If continuation sheet 20 of 27

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 06/18/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
06/06/2025

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

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

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

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

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

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

(6) a statement indicating that there have

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

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 20 V 367

If continuation sheet 21 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level II and III incidents
in the Incident Response Improvement System
(IRIS) and notify the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment area where
services as required. The findings are:

Review on 5/22/25 of "Notification of CPS (Child
Protective Services) Involvement" dated 4/1/25
revealed:

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

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

-Admitted 10/24/24.

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

-Discharged 3/27/25.

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367| Continued From page 21 V 367

If continuation sheet 22 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

safety for both [FC #1] and others in the home,
the Resident was discharged from the facility
because the resident was physically and verbally
aggressive, displayed property destruction,
attempted to go awol, and made multiple
self-harm attempts and threats."

-"Course of Treatment ...Since admission
(10/24/24) to level three services, the resident
has shown constant regression to include
instances of property destruction, verbal and
physical aggression, attention-seeking behaviors,
false allegation of sexual assault [van driver,
school officials, residential staff (facility staff)],
AWOL attempts, suicidal ideations, and self-harm
attempts resulting in multiple hospitalizations ...
-Discharge Plan-The resident was IVC'd
(involuntarily committed), and [Facility] will
support the transition to a higher level of care
and/or alternate placement.

-Discharge Outcome-Discharged-Regression."

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

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

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

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 22 V 367

If continuation sheet 23 of 27

PRINTED: 06/18/2025

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
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 23 V 367

group home staff (FS #7); No Weapons; 17 YOA
(years of age) F/M; mixed female subj (subject)
has beat up all of the staff. has spit on the caller
(FS #7) and made threats to other reside
(clients)."

-1/24/25 13:51 (1:51pm), Child Abuse Complaint,
Self (facility), Notes: Not on scene. Intake report.
-1/24/25, "18:46 (6:46pm), Missing Person [Staff
#1], E911, Notes: Upon arrival | spoke with the
house manager (HM/QP#2), [HM/QP#2] who
stated at approximate 6:15 pm [Former Client #3
(FC#3)] left the residence (facility)...While on site
taking notes for the 81 report [FC #3]. She
(FC#3) she needed to get away for the moment
and went to [fast food restaurant]. [FC#3] stated
she would not leave the residence (facility) again
and would remain in side; Arrived back home
(facility)...19:25 (7:25pm); [FC#3] WF (white
female) blonde and blk (black) hair, blk jacket
and furry slides, oversized jackets, walking
towards [local restaurant], time lapse 20mins
(minutes)."

-2/8/25, 15:43 (3:43pm), Missing Person Child,
[FS#8], W911, Notes: Juvenile (FC #3) left in the
care of para professional [Staff #9], who stated
she will be transporting the juvenile to [County] for
further evaluation and placement, [FC #3];
Notified 2/8/25, 15:48 (3:48pm) twrds (towards)
shopping center black hoodie, navy blue baby
yoda pajama pants, [sneaker brand] shoes blk
and gry (grey) bag, and red crossbody purse left
on foot client ran away, 15 year old whit female
[FC#3]."

-3/21/25, "22:57 (10:27pm), Check Welfare, [Staff
#6], Notes:...One female juvenile (FC #1);
Prisoner in custody, 23:01 (11:01pm); Back at the
home (facility) but needs transport her to hospital;
heavy set female short Mohawk hair style [FC #1]
17 yo (year old); Female jumped out the window,
subject have a 73 episode (mental distress)."

Division of Health Service Regulation

STATE FORM

6809

OEHS511

If continuation sheet 24 of 27

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/18/2025

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
06/06/2025

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

-4/2/25, "9:45am, Child Abuse Complaint, Self;
Notes: DSS (Department of Social Services)
report; 3/27/25 18:56 (6:56pm) Mental
Commitment, Notes: [FC #1]..."

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

-No level II or Ill incidents reported.

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

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

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

-Had never written or submitted an incident
report.

-QPs were responsible for submitting reports in
IRIS.

Division of Health Service Regulation
STATE FORM

6809

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 24 V 367

If continuation sheet 25 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025
FORM APPROVED

Interview on 6/2/25 with the Home
Manager/QP#2 revealed:

-Qualified Professional (QP).

-She and QP #1 were responsible for reporting
incidents.

-Was unable to provide the facility's internal
incident reports.

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

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

-Was responsible for submitting incidents in IRIS.
-Had submitted IRIS report for FC #1's IVC on
3/27/25 and had not submitted any other level II
and Ill reports to IRIS.

-Was not aware she needed to submit report in
IRIS and HCPR for FC #1's 4/1/25 allegation of
Staff #4 kissing and attempting to touch FC #1.
-Had not submitted any other level II or III reports
in IRIS for FC #1 behaviors as described in FC
#1's 3/27/25 discharge summary.

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

Interview on 6/4/25 and 6/6/25 the Human
Resources/Compliance Consultant revealed:
-Contracted consultant.

-Responsible for overseeing reporting of
incidents.

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

-Was not aware of incidents from police report

Division of Health Service Regulation

STATE FORM

6808 OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 25 V 367

If continuation sheet 26 of 27

Division of Health Service Regulation

PRINTED: 06/18/2025

FORM APPROVED

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

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

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

Division of Health Service Regulation
STATE FORM 6899

OEHS511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 06/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 26 V 367

If continuation sheet 27 of 27

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

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

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

DEFICIENCY)

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

V 000} INITIAL COMMENTS Vv 000

Acomplaint survey was completed on February
26, 2025. The complaints were unsubstantiated
(intake #NC00226279,
#NC00226420,#NC00226539 and
#NC00227177). Deficiencies were cited.

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

This facility is licensed for 6 and has a current
census of 3. The survey sample consisted of 1
current.

This survey originally closed on February 11,
2025 but was reopened on February 12, 2025
due to additional complaints.

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

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

(X6) DATE

STATE FORM 6899 UK6Q11

If continuation sheet 1 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

are being provided.

c. Misappropriation of the property of a
healthcare facility.

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

e. Fraud against a health care facility or against
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 reviews and interviews, the
facility failed to report allegations of abuse,
neglect or exploitation to the Health Care
Personnel Registry (HCPR). The findings are:

Review of photographs received from Client #1's
Guardian at Litem Social Worker and the Facility
on 1/23/25 revealed:

-Client #1 had a one inch scratch on her chin and
and a half inch scratch on her neck.

-Client #1 had a scratch on the corner of her
mouth.

-Client #1 had a bruise the size of a quarter and 2
one inch scratches on her left shoulder.

-The bruise on Client #1's left shoulder was a light
brown color.

Review on 1/29/25 of the facility's Internal
Investigation Report revealed:

-On 1/21/25 the facility was notified by the local
Department of Social Services (DSS) that an
allegation of abuse was reported against Staff #2.
-DSS alleged Staff #2 injured Client #1 during a
Division of Health Service Regulation

STATE FORM

6899 UK6Q11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

If continuation sheet 2 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

restraint on 1/16/25.

-Staff #2 was suspended on 1/21/25 pending
investigation and had not returned.

-Pictures were taken of Client #1's injuries on
2/21/25.

-The internal investigation was still pending.
-No documentation of incident being reported to
the Healthcare Personnel Registry (HCPR).

Interview on 2/11/25 with Client #1 revealed:

-On 1/16/25 she became upset because Staff #2
was "provoking" her.

-Hit Staff #2 in the face.

-Staff #2 put her in a restraint to stop her (Client
#1) from hitting her.

-Staff #2's bracelets scratched her face during the
restraint.

-Staff #2 apologized for scratching her face.

-No injuries.

-The bruise in the picture was "old".

-Was not injured.

-Felt safe at the facility.

Interview on 2/11/25 with Client #3 revealed:
-On 1/16/25 Client #1 hit Staff #2 in the face.
-Staff #2 put Client #1 in a restraint.

-Witnessed Staff #2's bracelets scratch Client
#1's face.

-Did not witness how Client #1 got the bruise on
her left shoulder.

Interview on 2/11/25 with Client #4 revealed:

-"| don't know what was going on (1/16/25). | saw
[Client #1] in a restraint. [Staff #2's] bracelets
scratched her (Client #1) face, but it was not
intentional."

Attempted to interview Staff #2 on 2/11/25,
2/14/25 and 2/26/25, and left a voice message.
Staff #2 did not return calls. The Human
Division of Health Service Regulation

STATE FORM

6899 UK6Q11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132] Continued From page 3 V 132

Resource (HR)/Clinical Consultant said she
would have Staff #2 call me, but Staff #2 never
called.

Interview on 2/4/25 with House Manager/Qualified
Professional (QP) revealed:

-Gathered information for the incident report
regarding the restraint Staff #2 performed on
Client #1 on 1/16/25.

-Submitted the incident report to Clinical
Consultant #1.

-Did not know if the internal investigation was
complete.

-It was Clinical Consultant #1's responsibility to do
the internal investigation.

-It was Clinical Consultant #1's responsibility to
report to the HCPR.

Interview on 2/10/25 with Clinical Consultant #1
revealed:

-Staff #2 was suspended upon notification of the
allegation of abuse on 1/21/25.

-It is the House Manager/ QP's responsibility to
submit incident reports and report to HCPR.
-Would review job duties with the House
Manager/QP.

V 537| 27E .0108 Client Rights - Training in Sec Rest & | V 537

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
competence in the proper use of and alternatives
to these procedures. Facilities shall ensure that
staff authorized to employ and terminate these

Division of Health Service Regulation

STATE FORM 6899

UK6Q11

If continuation sheet 4 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

procedures are retrained and have demonstrated
competence at least 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 shall 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

rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

Division of Health Service Regulation

STATE FORM 6899

UK6Q11

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

DEFICIENCY)
V 537] Continued From page 4 V 537

If continuation sheet 5 of 9

PRINTED: 03/07/2025

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
Cc
MHLO013-240 B. WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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 537] Continued From page 5 V 537
(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
competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and

Division of Health Service Regulation
STATE FORM 6899 UK6Q11 If continuation sheet 6 of 9

PRINTED: 03/07/2025

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
Cc
MHLO013-240 B. WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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 537] Continued From page 6 V 537

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);

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

(2) The Division of MH/DD/SAS may

Division of Health Service Regulation
STATE FORM 6899 UK6Q11 If continuation sheet 7 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

review/request this documentation at any time.
(1) 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.

(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 1 of 3 audited staff (#2)
demonstrated competency in the proper use of
restrictive interventions. The findings are:

Review on 1/28/25 of Staff #2's employee record
revealed:

-Hire date of 2/22/23.

-National Crisis Intervention Plus (NCI+) training
dated 2/19/24.

Review on of 2/11/25 the facility's incident report
dated 1/21/25 revealed:

-Client #1 had to be restrained by Staff #2 due to
physical aggression by Client #1.

-Client #1 was scratched on her chin and chin on
the left side of her face by Staff #2's bracelets
while trying to put her (Client #1) in a restraint.

Interview on 2/11/25 with Client #1 revealed:

-On 1/16/25 she became upset because Staff #2
was "provoking" her.

Division of Health Service Regulation

STATE FORM

6899 UK6Q11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537} Continued From page 7 V 537

If continuation sheet 8 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-240 B. WING

NAME OF PROVIDER OR SUPPLIER
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC. CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

PRINTED: 03/07/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-Hit Staff #2 in the face.

-Staff #2 put her in a restraint to stop her (Client
#1) from hitting her.

-Staff #2's bracelets scratched her face during the
restraint.

-Staff #2 apologized for scratching her face.

-No injuries.

-The bruise in the picture was "old".

-Was not injured.

-Felt safe at the facility.

Interview on 2/11/25 with Client #3 revealed:
-On 1/16/25 Client #1 hit Staff #2 in the face.
-Staff #2 put Client #1 in a restraint.
-Witnessed Staff #2's bracelets scratch Client
#1's face.

Interview on 2/11/25 with Client #4 revealed:

-"| don't know what was going on. | saw [Client
#1] in a restraint. [Staff #2's] bracelets scratched
her (Client #1) face, but it was not intentional."

Attempted to interview Staff #2 on 2/11/25,
2/14/25 and 2/26/25, and left a voice message.
Staff #2 did not return calls. The Human
Resource (HR)/Clinical Consultant said she
would have Staff #2 call me, but Staff #2 never
called.

Interview on 2/11/25 with the HR/Clinical
Consultant #2/ NCI+ Instructor revealed:

-Last did NCI+ refresher training on 2/19/24.

-"If she (Staff #2) had performed the restraint
correctly she would not have scratched [Client
#1)."

-Staff #2 will receive more training in NCI+ before
she could return to work.

Division of Health Service Regulation

STATE FORM 6899

UK6Q11

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

DEFICIENCY)
V 537 | Continued From page 8 V 537

If continuation sheet 9 of 9

inspection_type: MHLCS Complaint