facility_name: Heaven's Gate

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

raw_content:
PRINTED: 12/18/2025
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

R
MHL013-247 8. WING —____________. 42/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
CONCORD, NC 28027

‘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)

HEAVEN'S GATE

INITIAL COMMENTS

An annual, complaint and follow up survey was.
completed on 12/10/25. The complaints were
unsubstantiated (intake #NC00233701 and
#NC00234816). 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 4 and has a current
census of 4. The survey sample consisted of
audits of 4 current clients.

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

C 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
tequired 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
during child or adolescent sleep hours is as
follows:

(1) two direct care staff shall be present
and one shall be awake for one through four

£59511

Cc RECEIVED
PEC 30 2025
DHSR-MH Licensure Sect

Eternal Haven’s Plan of Corrections
1) TAG V296 —- 10A NCAC 27G .1704
Minimum Staffing Requirements
Corrective Action

Effective immediately, the facility has revised its staffing and transportation
procedures to ensure compliance with minimum staffing requirements at all times,
including during client transportation. The deficiency was corrected with the
facility requiring two direct care staff to be present during client transportation.

This deficiency was corrected with a staff meeting instructing the staffing
ratios that apply during transportation. Reoccurrence will be prevented via
transportation plans being reviewed quarterly to ensure compliance with minimum
staffing requirements.

Responsible Person
Executive Director
2) TAG V364 - G.S. 122C-62
Client Rights — Privacy and Supervision

Corrective Action

Effective immediately, the facility reinforced privacy expectations related to
client bedrooms, therapy sessions, and phone calls. Deficiency correction occurs
via staff being re-trained on all client rights, including appropriate supervision and
respect for privacy. Reoccurrence will be prevented via client rights being re-
vamped within staff training.

Responsible Person

Qualified Professional / Executive Director

3) TAG V366 — 10A NCAC 27G .0603 & 4) TAG V367 - 10A NCAC 27G .0604
Incident Response Requirements
Corrective Action

The facility has revised its incident response procedures to ensure that all
Level I, II, and III incidents are managed in accordance with NCAC requirements.
Staff were retrained on IRIS and incident response requirements, regulations, and
expectations. Reoccurrence will be prevented via the designee reviewing all
incident reports quarterly to ensure compliance with response requirements.

Responsible Person

Executive Director / Associate Professional

inspection_type: MHLCS Annual  Complaint and Follow-up


state: NC

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

raw_content:
Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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

An annual, complaint and follow up survey was
completed on 12/10/25. The complaints were
unsubstantiated (intake #NC00233701 and
#NC00234816). 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 4 and has a current
census of 4. The survey sample consisted of
audits of 4 current clients.

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

10A 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
during child or adolescent sleep hours is as
follows:

(1) two direct care staff shall be present
and one shall be awake for one through four

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

STATE FORM

V 000

V 296

6808 £59511

TITLE

(X6) DATE

If continuation sheet 1 of 34

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 296] Continued From page 1 V 296

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 reviews, and
interviews the facility failed to ensure the
minimum staffing ratio of two staff for up to four
adolescents. The findings are:

Observation on 12/1/25 of the facility at
approximately 3:12pm revealed:
-Licensee/Executive Director/Associate
Professional (Licensee/ED/AP) arrived at the
facility driving a van alone with three clients
(clients #1 #2, #4).
Division of Health Service Regulation
STATE FORM

6809

£59511

If continuation sheet 2 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

-No other staff was in the van.

Review on 11/18/25 of client #1's record revealed:
-Age 16 years old.

-Admitted 5/9/25.

-History of Self Injurious Behaviors (SIBs),
trauma.

-Diagnoses: Post Traumatic Stress Disorder
(PTSD), With Derealization Symptoms; Major
Depressive Disorder (MDD), Recurrent Episode,
in Partial Remission.

Review on 11/18/25 of client #2's record revealed:
-Age 14 years old.

-Admitted 3/25/25.

-History of aggression, SIBs.

-Diagnoses: Adjustment Disorder, with Mixed
Disturbance of Emotions and Conduct; Other
Trauma and Stressor-Related Disorder; Major
Depressive Disorder, Recurrent Episode, Severe,
Without Psychotic Features.

Review on 11/18/25 of client #3's record revealed:
-Age 13 years old.

-Admitted 4/8/25.

-Discharged 11/17/25.

-History of aggression, SIBs.

-Diagnoses: Attention Deficit Hyperactivity
Disorder (ADHD), Combined Presentation;
Oppositional Defiant Disorder (ODD); Unspecified
Anxiety Disorder; Unspecified Trauma and Stress
Related Disorder; Unspecified Depressive
Disorder; Unspecified Disruptive, Impulse and
Conduct Disorder.

Review on 11/24/25 of client #4's record revealed
-Age 14 years old.

-Admitted 8/15/25.

-History of SIBs, elopement, aggression.
-Diagnoses: ADHD, combined presentation;

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 296] Continued From page 2 V 296

If continuation sheet 3 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

PTSD; ODD; MDD, Single Episode, Moderate.

Interview on 12/1/25 with client #1 revealed:
-Two staff worked in the morning, "sometimes
one (staff) if someone has a family emergency."
-Two staff worked at night.

-Two staff transported "coming from school the
two staff are [staff #1] and [staff #3]."

-The "only staff that had worked alone was when
[staff #3] was going to get his dog (date unknown)
and we (clients) stayed in the car while he got his
dogs. We were in the car a few minutes. He
(staff #3) lives in an apartment, so it doesn't take
long."

-Two staff transported clients, "[Licensee/ED/AP]
picks us up (from school) alone, but he counts as
two people."

Interview on 12/1/25 with client #2 revealed:
-Two staff worked in the morning "when awake,
two staff coming home from school, two staff at
night."

-There had never been a time when staff worked
a shift alone or a time when one staff was running
late for a shift.

-One staff transported.

-"If there is something important going on and
[Licensee/ED/AP] had to run out and get
something, one staff would be here."

Interview on 12/1/25 with client #3 revealed:
-"Sometimes one" staff worked on shift,
"sometimes two, usually at night or sometimes in
the morning there would be one staff."

-He (Licensee/ED/AP) wasn't in the facility for one
of the fights (date unknown) and he was laughing
on the phone over the camera (facility); he was
laughing at the situation of me crashing out.

Attempted interview on 12/1/25 with client #4

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 296 | Continued From page 3 V 296

If continuation sheet 4 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 296] Continued From page 4

revealed:
-Didn't want to talk.
-Refused to be interviewed.

Attempted interview on 12/9/25 with staff #1
unsuccessful due to no callback prior to survey
exit.

Interview on 12/5/25 with the AP revealed:

-Two staff worked each shift, two staff at bedtime,
two staff in the morning and no one staff working
alone.

-Two staff transported clients and "yes, there are
times when staff will transport alone and one staff
is at the home (facility)."

Interview on 12/2/25 with the Qualified Profession
revealed:

-Two staff worked on each shift.

-"| don't know if staff has worked a shift alone."
-When at the facility two staff worked, "so | can't
say if they (facility) have or haven't (worked
alone); to my knowledge there are two (staff)
when clients are sleeping, but I'm not there on
night shift."

-All staff provided transportation and
Licensee/ED/AP assisted with transportation to
doctor's appointments.

-"| don't know if one staff transport or not. | don't
want to give false information, | don't know."

Interviews on 11/18/25 and 12/4/25 with the
Licensee/ED/AP revealed:

-Was not aware that the minimum staffing ratio
applied to transporting clients in the community.
-Two staff worked each shift.

-There was not a time when staff worked a shift
alone.

-"| was in the car with that one incident...that was
sometime in November (2025)...staff [staff #1]
Division of Health Service Regulation

STATE FORM

V 296

6808 £59511

If continuation sheet 5 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 296 | Continued From page 5 V 296
was present, it was a fight (clients #2 and #3)...1
was in the car and i was not in the house."
-Staff used the van for transportation and two
staff "regularly transport, but there is times when
one staff will transport clients, that happens very
infrequently."
V 364} G.S. 122C- 62 Additional Rights in 24 Hour V 364

Facilities

§ 122C-62. Additional Rights in 24-Hour
Facilities.

(a) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-61, each adult client
who is receiving treatment or habilitation in a
24-hour facility keeps the right to:

(1) Send and receive sealed mail and have
access to writing material, postage, and staff
assistance when necessary;

(2) Contact and consult with, at his own expense
and at no cost to the facility, legal counsel, private
physicians, and private mental health,
developmental disabilities, or substance abuse
professionals of his choice; and

(3) Contact and consult with a client advocate if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each adult client may
exercise these rights at all reasonable times.

(b) Except as provided in subsections (e) and (h)
of this section, each adult client who is receiving
treatment or habilitation in a 24-hour facility at all
times keeps the right to:

(1) Make and receive confidential telephone
calls. All long distance calls shall be paid for by
the client at the time of making the call or made
collect to the receiving party;

(2) Receive visitors between the hours of 8:00
a.m. and 9:00 p.m. for a period of at least six

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 6 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 6 V 364

hours daily, two hours of which shall be after 6:00
p.m.; however visiting shall not take precedence
over therapies;

(3) Communicate and meet under appropriate
supervision with individuals of his own choice
upon the consent of the individuals;

(4) Make visits outside the custody of the facility
unless:

a. Commitment proceedings were initiated as
the result of the client's being charged with a
violent crime, including a crime involving an
assault with a deadly weapon, and the
respondent was found not guilty by reason of
insanity or incapable of proceeding;

b. The client was voluntarily admitted or
committed to the facility while under order of
commitment to a correctional facility of the
Division of Adult Correction of the Department of
Public Safety; or

c. The client is being held to determine capacity
to proceed pursuant to G.S. 15A-1002;

A court order may expressly authorize visits
otherwise prohibited by the existence of the
conditions prescribed by this subdivision;

(5) Be out of doors daily and have access to
facilities and equipment for physical exercise
several times a week;

(6) Except as prohibited by law, keep and use
personal clothing and possessions, unless the
client is being held to determine capacity to
proceed pursuant to G.S. 15A-1002;

(7) Participate in religious worship;

(8) Keep and spend a reasonable sum of his
own money;

(9) Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes;
and

(10) Have access to individual storage space for
his private use.

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 7 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 7 V 364

(c) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-57 and G.S.
122C-59 through G.S. 122C-61, each minor client
who is receiving treatment or habilitation in a
24-hour facility has the right to have access to
proper adult supervision and guidance. In
recognition of the minor's status as a developing
individual, the minor shall be provided
opportunities to enable him to mature physically,
emotionally, intellectually, socially, and
vocationally. In view of the physical, emotional,
and intellectual immaturity of the minor, the
24-hour facility shall provide appropriate
structure, supervision and control consistent with
the rights given to the minor pursuant to this Part.
The facility shall also, where practical, make
reasonable efforts to ensure that each minor
client receives treatment apart and separate from
adult clients unless the treatment needs of the
minor client dictate otherwise.

Each minor client who is receiving treatment or
habilitation from a 24-hour facility has the right to:
(1) Communicate and consult with his parents or
guardian or the agency or individual having legal
custody of him;

(2) Contact and consult with, at his own expense
or that of his legally responsible person and at no
cost to the facility, legal counsel, private
physicians, private mental health, developmental
disabilities, or substance abuse professionals, of
his or his legally responsible person's choice; and
(3) Contact and consult with a client advocate, if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each minor client
may exercise these rights at all reasonable times.
(d) Except as provided in subsections (e) and (h)
of this section, each minor client who is receiving
treatment or habilitation in a 24-hour facility has

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 8 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 8 V 364

the right to:

(1) Make and receive telephone calls. All long
distance calls shall be paid for by the client at the
time of making the call or made collect to the
receiving party;

(2) Send and receive mail and have access to
writing materials, postage, and staff assistance
when necessary;

(3) Under appropriate supervision, receive
visitors between the hours of 8:00 a.m. and 9:00
p.m. for a period of at least six hours daily, two
hours of which shall be after 6:00 p.m.; however
visiting shall not take precedence over school or
therapies;

(4) Receive special education and vocational
training in accordance with federal and State law;
(5) Be out of doors daily and participate in play,
recreation, and physical exercise on a regular
basis in accordance with his needs;

(6) Except as prohibited by law, keep and use
personal clothing and possessions under
appropriate supervision, unless the client is being
held to determine capacity to proceed pursuant to
G.S. 15A-1002;

(7) Participate in religious worship;

(8) Have access to individual storage space for
the safekeeping of personal belongings;

(9) Have access to and spend a reasonable sum
of his own money; and

(10) Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes.
(e) No right enumerated in subsections (b) or (d)
of this section may be limited or restricted except
by the qualified professional responsible for the
formulation of the client's treatment or habilitation
plan. A written statement shall be placed in the
client's record that indicates the detailed reason
for the restriction. The restriction shall be
reasonable and related to the client's treatment or

Division of Health Service Regulation
STATE FORM

6809

If

continuation sheet 9 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 9

habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional at least every seven days,
at which time the restriction may be removed.
Each evaluation of a restriction shall be
documented in the client's record. Restrictions on
rights may be renewed only by a written
statement entered by the qualified professional in
the client's record that states the reason for the
renewal of the restriction. In the case of an adult
client who has not been adjudicated incompetent,
in each instance of an initial restriction or renewal
of a restriction of rights, an individual designated
by the client shall, upon the consent of the client,
be notified of the restriction and of the reason for
it. In the case of a minor client or an incompetent
adult client, the legally responsible person shall
be notified of each instance of an initial restriction
or renewal of a restriction of rights and of the
reason for it. Notification of the designated
individual or legally responsible person shall be
documented in writing in the client's record.

This Rule is not met as evidenced by:

Based on observation, record reviews and
interviews the facility failed to ensure client rights
to privacy in a 24 hour facility affecting 3 of 4
current clients. The findings are:

Observation at the facility on 12/1/25 at
approximately 4:04pm revealed:

-The survey interview was interrupted when the
Licensee/Executive Director/Associated
Professional (Licensee/ED/AP) entered the
Division of Health Service Regulation

STATE FORM

V 364

6808 £59511

If continuation sheet 10 of 34

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

HEAVEN'S GATE

MHL013-247

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
12/10/2025

bedroom of client #1 without knocking.

-Client #1 stopped talking.

-The Licensee/ED/AP upon entering client #1's
bedroom stated, "I think this belongs to you",
placed a light brown folder on the top of client's
dresser, and exited client #1's bedroom.
-Client #1 resumed speaking.

Review on 11/18/25 of client #1's record revealed:
-Age 16 years old.

-Admitted 5/9/25.

-Diagnoses: Post Traumatic Stress Disorder
(PTSD), With Derealization Symptoms; Major
Depressive Disorder (MDD), Recurrent Episode,
in Partial Remission.

Review on 11/18/25 of client #2's record revealed:
-Age 14 years old.

-Admitted 3/25/25.

-Diagnoses: Adjustment Disorder, with Mixed
Disturbance of Emotions and Conduct; Other
Trauma and Stressor-Related Disorder; Major
Depressive Disorder, Recurrent Episode, Severe,
Without Psychotic Features.

Review on 11/18/25 of client #3's record revealed:
-Age 13 years old.

-Admitted 4/8/25.

-Discharged 11/17/25.

-Diagnoses: Attention Deficit Hyperactivity
Disorder (ADHD), Combined Presentation;
Oppositional Defiant Disorder (ODD); Unspecified
Anxiety Disorder; Unspecified Trauma and Stress
Related Disorder; Unspecified Depressive
Disorder; Unspecified Disruptive, Impulse and
Conduct Disorder.

Review on 11/24/25 of client #4's record revealed
-Age 14 years old.

-Admitted 8/15/25.

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 364] Continued From page 10 V 364

If continuation sheet 11 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 11

-Diagnoses: ADHD, combined presentation;
PTSD; ODD; MDD, Single Episode, Moderate.

Interview on 12/1/25 with client #1 revealed:
-Able to make phone calls, "staff is there with me,
they sometimes supervise us (clients); it's (phone
call) not on speaker, it can be on speaker if they
(staff) want it to be or if we (clients) want it to be."
-Saw the therapist twice weekly and was able to
get a session when she wanted one.

-Was able to talk with the therapist privately.
-Staff had come in her bedroom "because of the
bathroom and because they (staff) have to check
on us (clients). Sometime, | ask them (staff) to
come in (bedroom)."

Interview on 12/1/25 with client #2 revealed:
-Phone calls were made with staff present, but
were not placed on speaker.

-Had therapy twice weekly and "it's private."
-Staff would sometimes come in the session, "just
in case | need them (staff), | ask them , and when
they come in | get more support for me and | feel
comfortable."

Interview on 12/1/25 with client #3 revealed:
-"Hardly ever was able to make calls because
they (staff) would say 'no, you have to do this or
that' and | didn't get the calls the court said | was
supposed to get."

-The "court" said she could get thirty minutes
phone calls and usually only got five to ten
minutes of phone time.

-"They (staff) were sitting on the couch beside me
but the call was not on speaker."

-Staff had walked into her therapy sessions.
-"The therapy session was in my room (bedroom)
and the staff would walk in and | would ask them
to leave and they wouldn't leave. Usually it was
[Licensee/Executive Director/Associate
Division of Health Service Regulation

STATE FORM

V 364

6808 £59511

If continuation sheet 12 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

Professional (Licensee/ED/AP)] and he would sit
down and start talking, that would make me stop
talking because he was in there (therapy session)
and | wouldn't talk at all; the therapist wouldn't
say anything they would just talk together, the
therapist was [Licensed Professional (LP)]."

Attempted interview on 12/1/25 with client #4
revealed:

-Didn't want to talk.

-Refused to be interviewed.

Interview on 11/21/25 with client #3's Department
of Social Services Social Worker (DSS SW)
revealed:

-The facility's discipline plan "directly violated
court orders that mandated" client #3 have phone
and video calls with her legal guardian/mother
(LG/mother) "as frequently as possible...these
calls included her siblings as well."

-Client #3 had reported requests to call the DSS
SW and the facility denied her requests.

-The facility's "unwillingness to comply with
contact (phone)...made them come across as
unwilling to cooperate with permanency planning
and reunification efforts."

Attempted interview on 12/9/25 with staff #1
unsuccessful due to no callback prior to survey
exit.

Interview on 12/5/25 with the AP revealed:
-Phone calls were monitored by staff.

-"We (staff) sit with them (clients), they (clients)
are also in front room (living room) with staff
when they (client) make the call; they are able to
call within thirty minutes of request (to make a
call)."

Attempted interview on 12/5/25 with the LP was

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 12 V 364

If continuation sheet 13 of 34

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 364] Continued From page 13 V 364

unsuccessful due to no callback prior to survey
exit.

Interview on 12/4/25 with the Licensee/ED/AP
revealed:

-In November 2025 client #3 was upset and
requested to call her LG/mother.

-In response to client #3's request to call her
LG/mother, "staff replied they (staff) would call,
but she (client #3) needed to do her chores
because that is the structure, for phone calls to
happened after chores."

Interview on 12/9/25 with the Licensee/ED/AP
revealed:

-The facility had a behavior point system that
restricted client privileges and restriction of
phones use was not included.

-Client #3 had been able to call whenever she
wanted to make calls.

-"We (facility) don't allow phone calls until after
chores are done; that is to everyone that is not as
necessary as the legal guardian, like an aunt or
cousin, then they (clients) had to finish chores
before call them (non-essential family).

-Client #3's commands for staff to call her
LG/mother resulted in client #3's regressed
behaviors.

-Client #3 wanted to call her LG/mother on
11/13/25, made the request of staff and the
request was not granted, "we (staff) felt she
(client #3) was manipulating."

-Phone calls were not monitored, "but we only
monitor with DSS permission and DSS gave us
permission to monitor calls with [client #3]'s
LG/mother."

-"Clients definitely have privacy for calls, we
(staff) just monitor them (clients) by line of sight
so nothing bad happens. We don't put calls on
speaker."
Division of Health Service Regulation
STATE FORM

6809

£59511

If continuation sheet 14 of 34

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

HEAVEN'S GATE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
12/10/2025

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

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 366} 27G .0603 Incident Response Requirements V 366

If continuation sheet 15 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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

(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
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 16 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

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 incidents
affecting 4 of 4 current clients. The findings are:

Review on 11/24/25 of the facility's internal
incident reports revealed:

-9/2/25, client #4 self-injurious behaviors (SIBs).
-9/7/25, client #4 attempted to take vacuum cord
from client #3 and in the tugging back and forth
client #4 tripped over the vacuum.

-9/11/25, client #3 bruised arm at playground.
-9/18/25, client #3 SIBs.

-9/18/25, client #4 SIBs.

-9/20/25, client #3 SIBs

-9/21/25, client #3 and client #4 were verbally

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

arguing, client #4 hit client #3 resulting in a
physical altercation. Client #2 joined client #4 in
fighting client #3.

-9/21/25, client #4 SIBs.

-9/22/25, client #2 aggressive behavior, restraint.
-9/29/25, verbal altercation between client #4 and
client #3, client #4 threw a shoe hitting client #3 in
the face, resulting in a physical altercation.
-10/15/25, clients #1, #3, and #3 engaged in
"consenting kissing behavior."

-10/20/25, "During [client #4]'s
medication-management appointment, the client
became visibly distressed when discussion
turned towards incident or trauma-related history.
The client abruptly exited the provider's office
without permission. Staff (Licensee/Executive
Director/Associate Professional
(Licensee/ED/AP)) followed and observed the
client retrieving a bottle of alcohol from an
outdoor area and briefly consuming some of it
(alcohol). Staff immediately intervened, secured
the bottle, and transported the client to the local
emergency department for evaluation per facility
protocol. the client was medically cleared and
received no treatment. No injuries or further
behavioral escalation occurred. The client
returned safely to the facility, where staff provided
support and reviewed coping strategies.
-10/29/25, client #4 aggressive behavior,
destruction of property, bit finger of staff, restraint
-No documentation for physical between client
#3 and client #2 on 11/13/25.

Review on 12/10/25 of the facility's restrictive
intervention log revealed:

Restrictive interventions had been performed on
the following dates:

-8/8/25, client #2 was physically aggressive
toward a peer (unknown).

-9/21/25, client #4 became physically aggressive

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

with peer (client #3).

-9/21/25, client #2 became physically aggressive
with a peer (client #3).

-9/22/25, client #2 engaged in unsafe property
destruction and physical aggression.

-9/29/25, client #4 became physically aggressive
with a peer (client #3).

-10/29/25, client #4 engaged in property
destruction and became physically aggressive
with staff (Associate Professional).

-11/7/25, client #4 escalated from verbal
aggression into self-harming.

-11/14/25, client #3 became verbally aggressive
and engaged in property destruction.

Review on 11/14/25 of the North Carolina Incident
Response Improvement System (NC IRIS)
revealed:

-8/11/25 client #1, physical aggression,
elopement.

-8/20/25 client #1, elopement.

-9/2/25 client #3 elopement, law enforcement
contacted and client #3 allegation that bruise on
her arm from 8/28/25 altercation with a peer was
caused by the Licensee/ED/AP grabbing her.
-10/10/25 client #4 physical aggression,
destruction of property, elopement, suicidal
ideation (SI), law enforcement contacted.
-10/18/25, client #2 elopement.

-11/6/25 client #4 SIBs, SI, destruction of
property, law enforcement contacted.
-11/13/25 client #3 destruction of property, law
enforcement contacted.

-No level II incident report for client #3 bruising
her arm at the playground on 9/11/25.

-No level II incident reports for the physical
aggression of client #4 on client #3 on 9/21/25
and 9/29/25.

-No level II incident reports for the physical
aggression of client #4 and client #2 on client #3

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 18 V 366

If continuation sheet 19 of 34

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

HEAVEN'S GATE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
12/10/2025

on 9/21/25.

-No level Il incident report for client #4 observed
retrieving a bottle of alcohol from an outdoor area
and consuming it on 10/20/25.

-No level II incident report for physical aggression
between client #3 and client #2, when law
enforcement was called on 11/13/25.

-No level Il incident reports for restraints
performed on 8/8/25, 9/21/25, 9/22/25, 9/29/25,
10/29/25, 11/7/25 and 11/14/25.

Interview on 12/5/25 with the AP revealed:
-Staff on duty complete internal incident reports.
-"[Licensee/ED/AP] does IRIS."

Interview on 12/2/25 with the Qualified
Professional revealed:

-"[Licensee/ED/AP] is responsible for reporting in
IRIS."

-Internal incident reports were completed by staff
involved "then the IRIS report is completed by
[Licensee/ED/AP] most of the time."

Interview on 12/4/25 with the Licensee/ED/AP
revealed:

-"| believe" the AP is responsible for IRIS
reporting, "but when she is not available | help."
-Did not think that the client aggression should be
submitted as a level Il report in IRIS.

-Thought level II incidents were reported in IRIS if
law enforcement was called or if clients received
treatment at the hospital.

-Had not documented risk cause analysis to
describe how the facility attended to the health
and safety needs of clients involved, determined
the cause of the incident, developed and
implemented measures to prevent similar
incidents or assigned person(s) responsible for
implementation of the corrective and preventive

measures.

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 366] Continued From page 19 V 366

If continuation sheet 20 of 34

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

HEAVEN'S GATE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
12/10/2025

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(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.

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] 27G .0604 Incident Reporting Requirements V 367

If continuation sheet 21 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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

(c) Category A and B providers shall submit,

upon request by the LME, other information

obtained regarding the incident, including:

(1) hospital records including confidential

information;

(2) reports by other authorities; and

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

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

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

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

(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

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 22 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level II incidents in the
Incident Response Improvement System (IRIS)
and failed to notify the the Local Management
Entity (LME)/ Managed Care Organization (MCO)
responsible for the catchment area where
services are provided within 24 hours and 72
hours of becoming aware of the incident. The
findings are:

Review on 11/24/25 of the facility's internal
incident reports revealed:

-9/2/25, client #4 self-injurious behaviors (SIBs).
-9/7/25, client #4 attempted to take vacuum cord
from client #3 and in the tugging back and forth
client #4 tripped over the vacuum.

-9/11/25, client #3 bruised arm at playground.
-9/18/25, client #3 SIBs.

-9/18/25, client #4 SIBs.

-9/20/25, client #3 SIBs

-9/21/25, client #3 and client #4 were verbally
arguing, client #4 hit client #3 resulting in a
physical altercation. Client #2 joined client #4 in
fighting client #3.

-9/21/25, client #4 SIBs.

-9/22/25, client #2 aggressive behavior, restraint.
-9/29/25, verbal altercation between client #4 and
client #3, client #4 threw a shoe hitting client #3 in

the face, resulting in a physical altercation.

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

-10/15/25, clients #1, #3, and #3 engaged in
"consenting kissing behavior."

-10/20/25, "During [client #4]'s
medication-management appointment, the client
became visibly distressed when discussion
turned towards incident or trauma-related history.
The client abruptly exited the provider's office
without permission. Staff (Licensee/Executive
Director/Associate Professional
(Licensee/ED/AP)) followed and observed the
client retrieving a bottle of alcohol from an
outdoor area and briefly consuming some of it
(alcohol). Staff immediately intervened, secured
the bottle, and transported the client to the local
emergency department for evaluation per facility
protocol. the client was medically cleared and
received no treatment. No injuries or further
behavioral escalation occurred. The client
returned safely to the facility, where staff provided
support and reviewed coping strategies.
-10/29/25, client #4 aggressive behavior,
destruction of property, bit finger of staff, restraint

Review on 12/10/25 of the facility's restrictive
intervention log revealed:

Restrictive interventions had been performed on
the following dates:

-8/8/25, client #2 was physically aggressive
toward a peer (unknown).

-9/21/25, client #4 became physically aggressive
with peer (client #3).

-9/21/25, client #2 became physically aggressive
with a peer (client #3).

-9/22/25, client #2 engaged in unsafe property
destruction and physical aggression.

-9/29/25, client #4 became physically aggressive
with a peer (client #3).

-10/29/25, client #4 engaged in property
destruction and became physically aggressive
with staff (Associate Professional).

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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

If continuation sheet 24 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

-11/7/25, client #4 escalated from verbal
aggression into self-harming.

-11/14/25, client #3 became verbally aggressive
and engaged in property destruction.

Review on 11/14/25 of the North Carolina Incident
Response Improvement System (NC IRIS)
revealed:

-No documentation of a level II report submitted
for client #3 bruising her arm at the playground on
9/11/25.

-No documentation of a level II report submitted
the physical aggression of client #4 on client #3
on 9/21/25 and 9/29/25.

-No documentation of a level II report submitted
for the physical aggression of client #4 and client
#2 on client #3 on 9/21/25.

-No documentation of a level II report submitted
for client #4 observed retrieving a bottle of alcohol
from an outdoor area and consuming it on
10/20/25.

-No documentation of a level II report submitted
for physical aggression between client #3 and
client #2, when law enforcement was called on
11/13/25.

-No documentation of a level II report submitted
for restraints performed on 8/8/25, 9/21/25,
9/22/25, 9/29/25, 10/29/25, 11/7/25 and 11/14/25.

Interview on 12/5/25 with the AP revealed:
-Staff on duty complete internal incident reports.
-"[Licensee/ED/AP] does IRIS."

Interview on 12/2/25 with the Qualified
Professional revealed:

-"[Licensee/ED/AP] is responsible for reporting in
IRIS."

-Internal incident reports were completed by staff
involved "then the IRIS report is completed by

[Licensee/ED/AP] most of the time."

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 34

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

HEAVEN'S GATE

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
12/10/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 367

Vv 521

Continued From page 25

Interview on 12/4/25 with the Licensee/ED/AP
revealed:

-"| believe" the AP is responsible for IRIS
reporting, "but when she is not available | help."
-Did not think that the client aggression should be
submitted as a level II report in IRIS.

-Did not report in IRIS for client aggression
"because any aggressive or destructive act that
does not require police constitutes level |."
-Understood "threat to health and safety" as "like |
am profusely bleeding or can't walk."

-Thought level II incidents were reported in IRIS if
law enforcement was called or if clients received
treatment at the hospital.

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

27E .0104(e9) Client Rights - Sec. Rest. & ITO

10A NCAC 27E .0104 SECLUSION,
PHYSICAL RESTRAINT AND ISOLATION
TIME-OUT AND PROTECTIVE DEVICES USED
FOR BEHAVIORAL CONTROL

(e) Within a facility where restrictive interventions
may be used, the policy and procedures shall be
in accordance with the following provisions:

(9) Whenever a restrictive intervention is utilized,
documentation shall be made in the client record
to include, at a minimum:

(A) notation of the client's physical and
psychological well-being;

(B) notation of the frequency, intensity and
duration of the behavior which led to the
intervention, and any precipitating circumstance
contributing to the onset of the behavior;

(C) the rationale for the use of the intervention,
the positive or less restrictive interventions

Division of Health Service Regulation
STATE FORM

V 367

Vv 521

6809

If continuation sheet 26 of 34

PRINTED: 12/18/2025

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
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 521] Continued From page 26 Vv 521

considered and used and the inadequacy of less
restrictive intervention techniques that were used;
(D) a description of the intervention and the date,
time and duration of its use;

(E) a description of accompanying positive
methods of intervention;

(F) a description of the debriefing and planning
with the client and the legally responsible person,
if applicable, for the emergency use of seclusion,
physical restraint or isolation time-out to eliminate
or reduce the probability of the future use of
restrictive interventions;

(G) a description of the debriefing and planning
with the client and the legally responsible person,
if applicable, for the planned use of seclusion,
physical restraint or isolation time-out, if
determined to be clinically necessary; and

(H) signature and title of the facility employee
who initiated, and of the employee who further
authorized, the use of the intervention.

This Rule is not met as evidenced by:

Based on record reviews and interview, the
facility failed to ensure the necessary
documentation was in the client record when a
restrictive intervention was utilized affecting 4 of 4
current clients. The findings are:

Review on 11/18/25 of client #1's record revealed:
-Age 16 years old.

-Admitted 5/9/25.

-Diagnoses: Post Traumatic Stress Disorder
(PTSD), With Derealization Symptoms; Major
Depressive Disorder (MDD), Recurrent Episode,
in Partial Remission.

Review on 11/18/25 of client #2's record revealed:
-Age 14 years old.
Division of Health Service Regulation
STATE FORM

6809

£59511

If continuation sheet 27 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

-Admitted 3/25/25.

-Diagnoses: Adjustment Disorder, with Mixed
Disturbance of Emotions and Conduct; Other
Trauma and Stressor-Related Disorder; Major
Depressive Disorder, Recurrent Episode, Severe,
Without Psychotic Features.

Review on 11/18/25 of client #3's record revealed:

-Age 13 years old.

-Admitted 4/8/25.

-Discharged 11/17/25.

-Diagnoses: Attention Deficit Hyperactivity
Disorder (ADHD), Combined Presentation;
Oppositional Defiant Disorder (ODD); Unspecified
Anxiety Disorder; Unspecified Trauma and Stress
Related Disorder; Unspecified Depressive
Disorder; Unspecified Disruptive, Impulse and
Conduct Disorder.

Review on 11/24/25 of client #4's record revealed
-Age 14 years old.

-Admitted 8/15/25.

-Diagnoses: ADHD, combined presentation;
PTSD; ODD; MDD, Single Episode, Moderate.

Review on 11/24/25 of the facility's internal
incident reports revealed:

-9/22/25, "Around about 6:30pm, staff instructed
everyone in the house (facility) to return items
that were given to others to share. During the
process of the exchange, [client #2] grew upset
that she had to return things. She (client #2)
started to throwing the items, which resulted in
staff intervening again and ask for the things to
be given directly to staff. She (client #2) grew
more agitated saying she wanted to fight other
clients. Staff restrained [client #2] and asked
others to go into their rooms. Staff restrained
[client #2] until she calmed down (under 1 min
(minute)). Once she was calm, we (staff) spoke

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 521] Continued From page 27 Vv 521

If continuation sheet 28 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

with her about her actions and she apologized.
Follow up action [client #2] placed on red
(behavior point) until October (2025). Staff
continue to monitor client and ensured a safe
environment."

-10/29/25, "Staff informed [client #4] that it was
time for his scheduled therapy session. [Client
#4] appeared agitated and frustrated from an
earlier situation at school. When reminded about
therapy, he stated he did not want to participate
and requested ten additional minutes. Staff
allowed this extension, but when the time elapsed
and therapy was prompted again, [client #4]
became more irritable and defiant, asking for
another ten minutes. Staff and the therapist
attempted to verbal de-escalation the client by
calmly engaging [client #4], checking in about his
emotions, and offering supportive statements.
[Client #4] responded by raising his voice, saying,
‘Get the hell out of my room,’ and slammed his
bedroom door. Staff continued using a calm tone
and encouraged him to utilize his resources and
discuss his feelings. At that point, [client #4]
became physically aggressive, charging toward
Staff and throwing her (staff) laptop onto the floor,
causing property damage. Staff assessed that
[client #4] was escalating toward unsafe
behaviors and that his actions posed a risk of
harm to himself and others. Given [client #4]'s
known history of head-banging and self-harm
when upset, Staff initiated a therapeutic hold in
accordance with [restrictive training provider]
protocol to ensure client safety. During the hold,
[client #4] bit Staff's finger (causing visible bite
marks) but no break in the skin. Staff maintained
composure, ensured [client #4]'s airway and body
were safe, and released the hold as soon as
[client #4] de-escalated. [Client #4] then ran to
the garage area to calm down, where he later
re-entered the home (facility) and apologized to

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 521] Continued From page 28 Vv 521

If continuation sheet 29 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

Staff for his behavior."

Review on 12/10/25 of the facility's restrictive
intervention log revealed:

Restrictive interventions had been performed on
the following dates:

-8/8/25, client #2 was physically aggressive
toward a peer (unknown).

-9/21/25, client #4 became physically aggressive
with peer (client #3).

9/21/25, client #2 became physically aggressive
with a peer (client #3).

-9/22/25, client #2 engaged in unsafe property
destruction and physical aggression.

-9/29/25, client #4 became physically aggressive
with a peer (client #3).

-10/29/25, client #4 engaged in property
destruction and became physically aggressive
with staff (Associate Professional).

-11/7/25, client #4 escalated from verbal
aggression into self-harming.

-11/14/25, client #3 became verbally aggressive
and engaged in property destruction.

Review on 11/24/25 of facility records revealed:
-No notation of the clients physical and
psychological well being.

-No notation of the frequency, intensity, and
duration of the behavior which led to the
intervention, and any precipitating circumstance
contributing to the onset of the behavior.

-The rationale for the use of the use of the
intervention, the positive or less restrictive
interventions considered and used and the
inadequacy of less restrictive intervention
techniques that were used.

-No notion of the description of the restrictive
intervention, or the date, time, and duration of its
use.

-No notion of a description of accompanying

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 521] Continued From page 29 Vv 521

If continuation sheet 30 of 34

Division of Health Service Regulation

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

MHL013-247

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

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

4111 ZEBULON AVENUE SW
CONCORD,

HEAVEN'S GATE

NC 28027

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
12/10/2025

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 521] Continued From page 30

positive methods of intervention.

-No notion of debriefing and planning with the
client and the legally responsible person, if
applicable, for the emergency use of seclusion,
physical restraint or isolation time-out to eliminate
or reduce the probability of the future use of
restrictive interventions.

-No description of the debriefing and planning
with the clients and their legally responsible
person for the planned use of seclusion, physical
restraint or isolation time out if determined to be
clinically necessary and

-No documentation of the signature and title of
the facility employee who initiated the use of the
restrictive interventions.

Interview on 2/10/25 with the Licensee/ED/AP
revealed:

-Was unaware that the above information needed
to be documented in the client record.

-Would ensure that all that information would be
documented going forward.

V 539} 27F .0102 Client Rights - Living Environment

10A NCAC 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 least 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,

Division of Health Service Regulation
STATE FORM

Vv 521

V 539

6809

If continuation sheet 31 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 539

Continued From page 31

and with respect for the physical structure. Any
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, record reviews, and
interviews, the facility failed to ensure there was
an atmosphere conductive to uninterrupted sleep
during scheduled sleeping hours and accessible
areas for personal privacy affecting 2 of 4 clients (
#1 and #3). The findings are:

Observation on 11/14/25 in the facility at
approximately 5:20pm revealed:

-Locked bathroom in the bedroom occupied by
client #1 and client #3.

-Staff #1 used a key to locked the bathroom in the
bedroom occupied by client #1 and client #3.
-Toilet paper, paper towels, small clear plastic
cups, and paper cups were stored in the
bathroom in the bedroom occupied by client #1
and client #3.

Review on 11/18/25 of client #1's record revealed:
-Age 16 years old.

-Admitted 5/9/25.

-Diagnoses: Post Traumatic Stress Disorder
(PTSD), With Derealization Symptoms; Major
Depressive Disorder (MDD), Recurrent Episode,
in Partial Remission.

Review on 11/18/25 of client #3's record revealed:
-Age 13 years old.

-Admitted 4/8/25.

-Discharged 11/17/25.

-Diagnoses: Attention Deficit Hyperactivity
Disorder (ADHD), Combined Presentation;

V 539

Division of Health Service Regulation

STATE FORM

6808 £59511

If continuation sheet 32 of 34

Division of Health Service Regulation

PRINTED: 12/18/2025
FORM APPROVED

Oppositional Defiant Disorder (ODD); Unspecified
Anxiety Disorder; Unspecified Trauma and Stress
Related Disorder; Unspecified Depressive
Disorder; Unspecified Disruptive, Impulse and
Conduct Disorder.

Interview on 12/1/25 with client #1 revealed:
-The bathroom was used by staff and staff came
in her bedroom "because of the bathroom."
-"When we're (clients #1 and #3) asleep, they
(staff) will go to the bathroom or we will step out
of the room (bedroom).”

Interview on 11/14/25 with staff #1 revealed:
-The bathroom in the bedroom occupied by client
#1 and client #3 was not a staff bathroom.

-The bathroom in the bedroom occupied by client
#1 and client #3 was used for storage by staff.
-Clients were able to request use of the bathroom
in the bedroom occupied by client #1 and client
#3, "and staff will unlock it."

-Clients "only use the toilet and sink" in the
bathroom in client #1 and client #3's bedroom.

Interview on 12/5/25 with the Associate
Professional (AP) revealed:

-"Yes, the staff use the bathroom in [client #1]'s
bedroom, we (staff) enter her (client #1) bedroom
and use the key for the bathroom door when she
is sleeping."

-Clients were only permitted to use the bathroom
in client #1's bedroom when the client bathroom
on the hallway was in use.

-"They (clients) don't shower in there (bathroom
in client #1's bedroom) and the door is always
locked."

Interview on 12/4/25 with the Licensee/Executive
Director/AP revealed:
-"That bathroom is just storage. | don't know

Division of Health Service Regulation

STATE FORM

6808 £59511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-247 12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 539] Continued From page 32 V 539

If continuation sheet 33 of 34

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

HEAVEN'S GATE

MHL013-247

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

(X3) DATE SURVEY
COMPLETED

FORM APPROVED

R
12/10/2025

what bathroom the staff use when working. Let
me ask the team. The other bath (client
bathroom on hallway) is client specific."

-Asked staff and replied, "yes, they (staff) use the
one (bathroom) in the bedroom (client #1).
-"Staff would have to go into her (client #1)
bedroom while she is sleeping to use the
bathroom and we (staff) are still watching them
(clients) as they sleep."

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 539] Continued From page 33 V 539

If continuation sheet 34 of 34

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation

(x4) 1D
PREFIX
TAG

Vv 000

V 108

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

Division of Health Service Regulation

IDENTIFICATION NUMBER:

(X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL013-247 BWING

HEAVEN'S GATE

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

INITIAL COMMENTS

A complaint survey was completed on 12/20/24
The complaint was unsubstantiated (Intake
#NC00224743). 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 0. The survey sample consisted of

audits of 2 former clients.

27G .0202 (F-l) Personnel Requirements Vv 108

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

10A 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
| bloodborne 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
to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
CONCORD, NC 28027

PRINTED: 01/09/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
12/20/2024

PROVIDER'S PLAN OF CORRECTION

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

DEFICIENCY)

(x5)

PLIER REPRESENTATIVE'S SIGNATURE

RECEIVED

DHSR-MH Licensure Sect

TITLE

a

AMD iy)

el Assoiole Prafecs

(X6) DATE

Son.1%, ROAST

it continuation sheet 1 of 6

A. Finding: 10A NCAC 27G .0202 PERSONNEL REQUIREMENTS

Corrective Action Steps:

The review reveled: “No documentation of training to meet the need of Former Client #1
as outlined in the treatment plan.”

Going forward, Eternal Haven will implement a consumer specific training. This includes
all specific psychiatric mental health diagnoses for each consumer.

— Party(s):

Evidence:
A consumer specific training for each consumer will come from consumer-based documents.
(Including, but not limited to PCP, CCA, Psychological Assessments, etc.)

By increasing the frequency of times we are looking at the staff files a week, this alleviates and
prevents this issue from reoccurrence.

B. Finding: 10A NCAC 27G .0604 INCIDENT REPORTING REQUIREMENTS FOR CATEGORY A
AND B PROVIDERS

Corrective Action Steps:
The review revealed: “was not reported within the required timeframe” & “No update
submitted to the LME request on 12/3/24 of the incident on 12/1/24”

| ensure all incidents reports are submitted in the IRIS incident
reporting on-line portal within 72 hours of learning about an incident, even yl
does not have all of the facts about an incident. (iris.ncdhhs.gov).

When ..:.: or is informed about new or additional information related
to the incident (including being informed by the LME), reac update the original
report and submit the updated information by the end of the next business day after becoming
aware of the information.

By increasing the frequency of times we are looking at the IRIS website a week, this alleviates
and prevents this issue from reoccurrence.

Evidence:
IRIS submissions will be printed and documented within the “Incident Report” binder.

inspection_type: MHLCS Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 01/09/2025

FORM APPROVED

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
10A 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
bloodborne 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
to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,

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

STATE FORM

6808 YF2D11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
MHL013-247 12/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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
Acomplaint survey was completed on 12/20/24.
The complaint was unsubstantiated (Intake
#NC00224743). 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 0. The survey sample consisted of
audits of 2 former clients.
V 108] 27G .0202 (F-I) Personnel Requirements V 108

(X6) DATE

If continuation sheet 1 of 6

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL013-247

PRINTED: 01/09/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
12/20/2024

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 reviews and interviews, the
facility failed to ensure 2 of 2 staff (Associate
Professional, Direct Care staff) received training
to meet the needs of the client as outlined in the
treatment plan. The findings are:

Review on 12/18/24 of Staff #1's personnel
record revealed:

- Date of Hire 11/15/24;

- Job Title Direct Care Staff;

- No documentation training to meet the need of
Former Client #1 as outlined in the treatment
plan.

Review on 12/5/24 of the Associate Professional's
personnel record revealed:

- Date of Hire 7/20/24;

- Job Title Associate Professional;

- No documentation of training to meet the need
of Former Client #1 as outlined in the treatment
plan.

Interview on 12/20/24 with the Associate
Professional revealed:

- "I'm going to be more attentive and update the
population served training."

Division of Health Service Regulation

STATE FORM

6809

YF2D11

HEAVEN'S GATE
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 108] Continued From page 1 V 108

If continuation sheet 2 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

HEAVEN'S GATE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
12/20/2024

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(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.

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] 27G .0604 Incident Reporting Requirements V 367

If continuation sheet 3 of 6

Division of Health Service Regulation

PRINTED: 01/09/2025

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
MHL013-247 12/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4111 ZEBULON AVENUE SW
HEAVEN'S GATE
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 3 V 367

(c) Category A and B providers shall submit,

upon request by the LME, other information

obtained regarding the incident, including:

(1) hospital records including confidential

information;

(2) reports by other authorities; and

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

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

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

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

(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

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 4 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-247

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

4111 ZEBULON AVENUE SW

HEAVEN'S GATE

PRINTED: 01/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
12/20/2024

(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to report all critical incidents in the Incident
Response Improvement System (IRIS) and notify
the Local Management Entity (LME)/Managed
Care Organization (MCO) responsible for the
catchment areas where services were provided
within 72 hours of becoming aware of the incident
affecting 1 of 1 Former Client (FC) (FC#1). The
findings are:

Review on 12/5/24 of Former Client #1's record
revealed:

- Admission date 11/16/24;

- Age 16;

- Diagnoses Major Depressive Disorder,
recurrent, moderate; Disruptive mood
Dysregulation Disorder; Intellectual
Developmental Disorder; Post Traumatic Stress
Disorder; Attention Deficit Hyperactivity Disorder.

Review on 12 /5/24 of the IRIS from November 1,
2024- December 5, 2024 revealed:

- Incident on 11/18/24 of FC #1's behavior of
property damage and physical was not reported
within the required timeframe, incident was
reported on 11/26/24;

- No update submitted to the LME request on
12/3/24 of the incident on 12/1/24 with FC #1 The
client became irate because she indicated that

Division of Health Service Regulation
STATE FORM

6809

YF2D11

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 4 V 367

If continuation sheet 5 of 6

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL013-247

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

4111 ZEBULON AVENUE SW

PRINTED: 01/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
12/20/2024

she did not want to be at the placement any
longer... Client yelled, used profanity and became
physically aggressive with staff. Client referred to
staff as "faggot b***h" and stated that she would
have her father come and "shoot staff." Client
then began scratching herself, reopening old cut
marks on her wrist. Neighbors contacted Law
enforcement, who responded to the scene and
witnessed the client's behavior. Staff then made
the decision to contact mobile crisis, as the
client's behaviors were not subsiding. Mobile
crisis responded and initiated the IVC process
after witnessing the client behaviors. Client also
indicated that she wanted to kill herself.
Eventually, staff was able to get the client to calm
down

and agree to be taken to the hospital. The
hospital decided to admit the client

as they felt she was unstable, and finished the
IVC, originally started by mobile crisis. The
request This IRIS report has been reviewed by
MCO staff. There is information missing or that
requires further explanation. Please see below for
the info that needs

to be completed. Once completed, please save
and resubmit this IRIS report. Please resubmit
within 5 days of the date of this notification. 1.
Enter Tailored Plan Client Record Number.

Division of Health Service Regulation
STATE FORM

6809

YF2D11

HEAVEN'S GATE
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 5 V 367

If continuation sheet 6 of 6