facility_name: Georgie's Helping Hand

raw_content:
PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Requlation

STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILOING:

MHL002-032 B. WING

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION
(GACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX (GACH CORRECTIVE ACTION SHOULD BE
TAG
v 000

GEORGIE'S HELPING HAND

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

INITIAL COMMENTS

An annual and follow up survey was completed
on 1/12/26. 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 5 and has a current
census of 4, The survey sample consisted of
audits of 3 current clients.

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

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
—
STATE FORM C7 @JRO1 REC EIV Eee sheet 1 of 52

DHSR-MH Licensure Sect

PRINTED: 01/22/2026
FORM APPROVED

‘STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

GEORGIE'S HELPING HAND

Continued From page 1

be
ny (during Their’ place
ere Gains Their Pl
GHA cbsihaely did and
This Rule is not met as evidenced by: pecieale Take re ba

Based on record reviews and interviews, the th 2 Chen:
facility failed to develop and implement treatment

admission for 3 of 3 audited clients (Clients #1, re ke ab

plans based on client needs within 30 days of ay re were 40: oto

#2 and #3). The findings are:

Review on 12/22/25 of Client #1's record

revealed: ih of

Date of Admission 8/15/25. : re Jas a a
-15 years old. \had

~Diagnoses of Oppositional Defiant Disorder

(ODD), Attention-Deficit Hyperactivity Disorder dna vs @ oe ovlop ree
(ADHD), Autism Spectrum Disorder and Anxiety ys dis id ralie
Disorder.

-No treatment plan. a Pesnates onl

Review on 12/22/25 of Client #2's record rans te

revealed: 60; , ce
-Date of Admission 9/17/25. we ¢
-14 years old. &

-Diagnoses of ODD and ADHD. ONG oe

-No treatment pian.

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

~Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.
-No treatment plan.

Division of Health Service Regulation

STATE FORM cae 8JROM continuation sheet 2 of 52

PRINTED: 01/22/2026
FORM APPROVED

‘STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIERICLIA (Q@) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL002-032 8. WING.

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

V 112] Continued From page 2

Review on 1/6/26 of a Computer Aided Dispatch
(CAD) list dated 8/1/25-1/5/26 from the local
sheriffs department revealed:

-Law enforcement was called to Geargie's
Helping Hand Group Home for a "Missing
Person" on 11/6/25 and 12/3/25. When Client #3
eloped from the facility.

Interview on 1/5/26 with the Coordinator and a

Behavior Specialist from the local schoo! where ; sia
Clients #1, #2 and #3 attended revealed: a t ireete ,
~"The facility does not share their (clients') {

behaviors, violence tendency, triggers ...we have

feared about [Client #2's] sexual comments just

by him being here ...[Client #2] has made

statements of wanting to kill himself ...said he had

a gun or a bomb ...I don’t know if this was a

problem prior to him coming here ...[Client #3] ran

away from the facility 2 times. If a kid (client) runs

from the group home on Saturday, we need to

know that on Monday ..."

arty
-Goals and interventions were "usually in their

ec
(clients’) folder (record).” we ares mel es

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the q , ) i
ec
ue

Y

Program Director revealed: > atte and/or
-He was “involved” with the treatment plan pai ed | uns Dura es
meetings as they were “usually held at the TMs: ber nen infol '
facility.” jenfS

t AOCY

Interview on 1/6/26 with the Qualified
Professional (QP) revealed:
-"\ believe" the therapist was responsible for
development of the treatment plans.
-Treatment plan "recommendations come from
where they (clients) were before and what their
interactions were, but that's not part of my forte. |
am limited on what | can speak. | don’t do that.
That's not what I do ..."

Division of Health Service Regulation

STATE FORM Sad BJRO11 IH continuation sheet 3 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION {DENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

‘SUMMARY STATEMENT OF DEFICIENCIES. PROVIDER'S PLAN OF CORRECTION
{EACH DEFICIENCY MUST BE PRECEDED @Y FULL. (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS REFERENCED ‘TO THE APPROPRIATE

GEORGIE'S HELPING HAND

Continued From page 3

interview on 1/5/26 with the Director/Licensee sal nts st

revealed: ech rich
-She would have to "pull up the computer for the

other service generated plans" that were kept in a eine
another office. in he ne Dist ucyT [em
fcc ins s ee
. fap

Review on 1/6/26 of an e-mail correspondence to
me aed

the Division of Health Service Regulation
surveyors received from the Director/Licensee i

rami Director/Licensee dated 1/6/26 he Fein Cy rr ing if an
-Attachments to the e-mail were the a) Day hove pet

Person-Centered Plans (PCPs) (treatment plans)

for Clients #1, #2 and #3. Nie vag CL
Client #1's PCP was dated 12/28/25 and Client

#3's PCP was dated 1/5/26, both after survey

entrance.
-Client #2's PCP was dated 9/13/25 and last ca
updated 12/31/25.

Interview on 1/8/26 with the Director/Licensee a spac
revealed: & Ui e |

-The PCPs were to be completed by the QP in ex
collaboration with the staff. "[QP] is responsible us, phe hae oe

.d did the PCPs you received (1/6/26)." Ane, ep

Onclore

Interviews on 1/6/26 and 1/12/26 with the ms an mM cfors Free Wve.
Executive Director/Licensee revealed: HK Rasta x fa

-The Program Director, the Director/Licensee and Hi ure! stor F .

the therapist were responsible for developing

treatment plans. 4 ede Bik nko aa
ua

This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule ao
violation and must be corrected within 45 days.

cei
ian mois e ees ee th
| Ws Seal bing wt Prar|

Division of Health Service Regulation

STATE FORM eco 8JRO11 if continuation sheet 4 of 52

27G .0209 (C) Medication Requirements

PRINTED: 01/22/2026
FORM APPROVED

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY

IDENTIFICATION NUMBER:

B. WING.

MHL002-032

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

(X4) 10. SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (CROSS-REFERENCED TO THE APPROPRIATE, DATE

DEFICIENCY)

HH Administrators and,

V 118} Continued From page 4

10ANCAC 27G .0209 MEDICATION
REQUIREMENTS g off sere by No Means
(c) Medication administration: Serious

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

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

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

(A) client's name;

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

(C) instructions for administering the drug;

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

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

LD) rating wre ;
Noclect Poll manner’ FP
the. administration of the.
Quand nner i

id ents Meds ions Wet e

odainistered ascend on,
te oe Cs

on the
Psion: usually rof Sith,

os
rae

l pf di
row dhe prescs ‘hv
sttles when the vente

OM

dadars une not ov
Nadiection, yepills were,

requested un ae.
per’, IN ON CFFOC

This Rule is not met as evidenced by:
Based on observation, record reviews, and
interviews, the facility failed to ensure prescription
Division of Health Service Regulation

STATE FORM ons aJRON continuation sheet 5 of 52

‘STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER:

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 5

and non-prescription drugs were only
administered to a client on the written order of a
physician and the MARs were kept current for 3
of 3 audited clients (Clients #1, #2 and #3). The
findings are:

Cross Reference: 10A NCAC 27G.0209
Medication Requirements (V123). Based on
record reviews and interviews, the facility failed to
ensure drug administration errors were reported
immediately to a physician or pharmacist for 3 of
3 audited clients (Clients #1, #2 and #3).

Review on 12/22/25 of Client #1's record
revealed:
-Physician's orders dated 9/3/25 for:

-Cetirizine Hydrochloride (HCL)
(allergies) 10 milligrams (mg) 1 tablet by mouth
(PO) daily.

-Montelukast Sodium (asthma) 10 mg 1
tablet PO daily.

-Qelbree Extended Release (ER) (ADHD)
200 mg 1 capsule PO daily.

-Metformin HCL (prediabetes) 500 mg 1
tablet PO daily.

-Fluoxetine HCL (depression) 10 mg 1
capsule PO every morning.
-Physician's order dated 11/11/25 to discontinue
Lexapro/escitalopram oxalate 10 mg.
-No physician's orders for:

-Aripiprazole (agitation) 5 mg 1 tablet PO at
bedtime (HS).

-Guanfacine (impulsivity/ODD) 4 mg ‘1 tablet
PO every evening.

-Oxcarbazepine (ADHD) 300 mg 1 tablet
PO every evening.

-Levocetirizine (allergies) 5 mg 1 tablet PO
avery evening.

-Fluoxetine HCL 20 mg 1 capsule PO daily.

Division of Health Service Regulation
STATE FORM

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

ayoid any avoilobili
eee ake r Lapies.

oa at

rial ‘
dat are

Ary vpdales abit, gallawding Me
Medi dation M nagemen
Pees pion of Pharr
ute ered and processed

oxcord i agly -
ore Phen Oaaies

been made Pons

ers
Physician vat. “erefaren
it Was OWT PrOC ice
sellow through, with
medi ectiong Once gil ed |
the phormacies onl nor

No. preseribed vedic i

if continuation sheet 6 of 52

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032
NAME OF PROVIDER OR SUPPLIER:

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

04/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 6

Review on 12/23/25 of a dispense sheet dated
8/1/25-12/23/25 obtained by Division of Health
Service Regulation (DHSR) surveyors on
12/23/25 from the local pharmacy which
dispensed Client #1's medications revealed:
-Cetirizine 10 mg 1 tablet PO daily prescribed
11/5/25; Dispensed 11/5/25, 12/5/25.
-Montelukast 10 mg 1 tablet PO daily prescribed
41/5/25; Dispensed 11/5/25, and 12/5/25.
-Qelbree 200 mg 1 capsule PO daily prescribed
9/2/25; Dispensed 9/15/25, 10/23/25, 11/24/25,
and 12/23/25.

-Metformin 500 mg 1 tablet PO daily prescribed
9/2/25; Dispensed 9/4/25.

-Metformin 500 mg 4 tablet PO every evening
prescribed 11/5/25; Dispensed 12/16/25.
-Fluoxetine 10 mg 1 capsule PO every moming
prescribed 9/2/25; Dispensed 9/20/25.
-Fluoxetine 20 mg 1 capsule PO daily prescribed
11/5/25; Dispensed 12/16/25.

-Aripiprazole 5 mg 1 tablet PO at HS prescribed
11/5/25; Dispensed 11/5/25, and 12/5/25.
~Guanfacine 4 mg 1 tablet PO at HS prescribed
11/5/25; Dispensed 11/5/25 and 12/12/25.
-Oxcarbazepine 300 mg 1 tablet PO at HS
prescribed 11/17/25; Dispensed 11/18/25 and
12/16/25.

-Levocetirizine 5 mg 1 tablet PO every evening
prescribed 10/2/25; Dispensed 10/2/25, 11/10/25,

and 12/12/25.
Observation on 12/22/25 at 2:00 pm of Client #1's
medications revealed:
-Fluoxetine HCL 20 mg 1 PO daily dispensed
12/16/25.
-Cetirizine HCL 10 mg 1 PO daily dispensed
4215/25.
-Montelukast Sodium 10 mg 1 PO daily
dispensed 12/5/25.
-Qelbree ER 200 mg 1 PO every moming
Division of Health Service Regulation
STATE FORM

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

GH Adminichtlors Lmmediofly

fevievied all Mediectton,

Adavaistrafion, Recor’ S
(Mahe) for cuter Cenk,
once the Sueyors informe

us of the concernf-
Bien GHH Arecustiv

d Ulector could, explat a .

sper’ dotumestabior
e Untbunayidt was

fe canasstert bos is.

BJRO11 If continuation sheet 7 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (42) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHL002-032 8. WING _________. 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

V 118] Continued From page 7 To To gucther dest ne.

dispensed 11/24/25. WS
-Aripiprazole 5 mg 1 PO at HS dispensed [gSue as rel b § uaveye 7;

12/5/25. Ay
-Guanfacine HCL ER 1 PO at HS dispensed an id medicatio ¥
Tere ‘ors

GEORGIE'S HELPING HAND

12/12/25. i 8
-Oxcarbazepine 300 mg 1 PO at HS dispensed li S en
12/16/25. Ay 0 ddress ed,
-Metformin HCL 500 mg 1 PO every evening le
dispensed 12/16/25. a Pet tine
-Levocetirizine 5 mg 1 PO every evening
dispensed 12/12/25,

Review on 12/22/25 at 12:30 pm-2:00 pm of ck A 1 of i
Client #1’s MARs dated 10/1/25-12/22/25 ” teense $5

revealed: ; Nu urge revievied all

-There were no consistent specified

administration time for cetirizine, montelukast, tons
Current Nod cof

Qelbree, or Fluoxetine. The time slots on the

October 2025 MARs were left blank, the 1c Qsecal) j
strat dans $0
November 2025 MARs listed administration times tt

of 6:30 am and 7:00 am, and the December 2025 rope”
MARS listed administration times of 6:30 am, 7:30 Pronse f on and 4 P
am, and 8:00 am. ,
-October: acm Nt is x vow ,
-Cetirizine was marked with an "X"

t
10/1/25-10/6/25 and left blank 10/7/25- 11/5/25. Staff caved pecuve'
-Montelukast was marked with an "X" “i

re-e educ OL

10/1/25-10/2/25 and left blank 10/3/25-10/31/25. Ni dudes

-Aripiprazole and guanfacine were listed, but Dune te rie i
neither were documented as administered ior adn nl sje i)
10/1/25-10/31/25.

-Oxcarbazepine was listed but not documented ther medio (o ag,

as administered 10/1/25-10/31/25.

-Levocetirizine was marked with an "X" from

10/1/25-10/2/25 and documented as.

administered 10/3/25-10/31/25.

-November:

-Montelukast was left blank 11/1/25-11/5/25.

-Metformin was not documented as administered

11/30/25.

Division of Health Service Regulation
STATE FORM om 8JROM Wcontinuation sheet 8 of 62

PRINTED: 01/22/2026

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

MHL002-032 B. WING —________ 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

‘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)

GEORGIE'S HELPING HAND

Continued From page 8

Fluoxetine 20 mg was not listed and fluoxetine HH Administrators x

10 mg continued be documented as administered |
11/5/25-11/30/25. ytSe Con ; OL |
~Aripiprazole and guanfacine were listed, but In Hous @ aud ip of a (

neither were documented as administered from . 0 dur g
11/1/25-11/4/25. Both were documented as. 8 r fh SICAL YX
administered 11/5/25-11/30/25. MA Rs

-Both oxcarbazepine and its brand-name iy ens Ute
formulation, Oxtellar, were listed concurrently on fece ! 4 -
the MAR. Oxcarbazepine was not documented as d . cation g ore Ok uy) nN
administered 11/1/25-11/30/25 and Oxtellar was Meare i

, re

marked with an "X" from 11/1/25-11/23/25 and . , ag rest J
was initialed as administered from s tere exactly Af di i Para) vu
1/24/25-11180125. ' include Cort ect é
-Levocetirizine was documented as administered 2a ay A
11/4/25-11/30/25.
-December: bose, Rouike, mt
-Fluoxetine 10 mg (instead of 20 mg) continued \ ocumento Loh +

lied 6 all

to be documented as administered ‘
12/1/25-12/15/25. Fluoxetine 10 mg was marked Th * ip
with an "X" from 12/16/25-12/31/25. Fluoxetine 20 is oud OP. P

mg was documented as administered from oS id ont rece ww

12/46/25-12/21/25. No administration was q 4 “,
documented on 12/22/25, medfedtio ng 46 ensure nd
-Montelukast was marked with a circle and no id Ye ate Gq)
staff initials on 12/5/25 and 12/22/25. On 12/6/25 oth fens 1G

montelukast was documented as administered at . rssue$ -
6:30 am, left blank for 7:30 am and marked with a pis for Sia! lac \

circle and no staff initials for 8:00 am.

-Qelbree was not documented as administered

12/22/25. The 6:30 am and 8:00 am time slots

were left blank and the 7:30 am time slot was

marked with a circle and no staff initials.

-Metformin was not documented as administered

12/21/25.

~Aripiprazole and guanfacine were documented

as administered 12/1/25-12/21/25.

-Oxtellar was not listed on the MAR; only the

generic medication oxcarbazepine was listed, and

it was not documented as administered

Division of Health Service Regulation
STATE FORM baad 8JRO11 if continuation sheet 9 of 52

PRINTED: 01/22/2026
FORM APPROVED

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

MHL002-032 B. WING

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

(x4) 10 ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE

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

Continued F 9
ai ies Gn Admunis Tre Ong h dea

-Levocetirizine was documented as administered revised anc| | ree ngaree
42/1/25-12/19/25 and on 12/21/25. On 12/20/25 tr
No administration was documented as the its M edi ‘eof dL wu nes |rak on

_ entry was left blank. foli t ensure, Cé l talree,
Bate on 12/22125 of Client #2's record si ne bH S A fe qui renesfs

wo physician's order for any administered All 5 Ke aff ¥ St ie ai nua

Review on 12/23/25 of a dispense sheet dated Nedicali TT im nist no on
8/4/25-12/23/25 obtained by DHSR surveyors on m
12/23/25 from the local pharmacy which il rece! ive, Yer Ttosn
dispensed Client #2's medications revealed: ) ah
-Desvenlafaxine succinate ER (depression) 100 ON pro pe’ preare dures
mg 1 tablet PO daily prescribed 4/13/25; fl proce q
Dispensed 9/29/25, 11/19/25, and 12/15/25. admin istrofi on pr

-Lurasidone (mood disorder) 60 mg 1 tablet PO dé eunenfos tere, fae ENE S
every evening prescribed 6/29/25; Dispensed

9/29/25. Quel error othe

-Clonidine (ADHD) ER 0.1 mg 1 tablet PO twice Rl | x
daily (BID) in the moming and afternoon Vill an

prescribed 8/3/25; Dispensed 10/1/25, 11/10/25.

-Clonidine 0.1 mg 4 tablet PO in the moming and Op ry Hoff ho ae campleted

1 tablet PO in the evening prescribed 11/19/25; io
Dispensed 11/19/25. Medrce: Adis a istroti f
-Clonidine 0.3 mg 1 tablet PO at HS prescribed ua a demo NS oft
11/19/25; Dispensed 11/19/25. thy will bef peach tHee|
-Trazodone (insomnia) 50 mg 1 tablet PO at HS See

prescribed 9/29/25; Dispensed 9/29/25. daunistor jeahid ERY
-Trazodone 50 mg 1 to 1 1/2 tablets PO at HS i as

prescribed 11/19/25; Dispensed 11/19/25.
-Qelbree ER 200 mg 1 capsule PO every morning
prescribed 10/30/25; Dispensed 10/30/25.
-Qelbree ER 200 mg 1 capsule PO daily at 1:00
pm prescribed 11/19/25; Dispensed 11/26/25,
-Omeprazole (heartburn) 20 mg 1 capsule PO
daily prescribed 11/19/25; Dispensed 41/19/25,
and 12/15/25,
Division of Health Service Regulation
STATE FORM e290 8JRON continuation sheet 10 of 52

GEORGIE'S HELPING HAND

‘STATEMENT OF DEFICIENCIES

)
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER:

GEORGIE'S HELPING HAND

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

01/12/2026

‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 10

-Vyvanse (ADHD) 60 mg 4 capsule PO every
morning prescribed 11/19/25; Dispensed
11/21/25.

-Vitamin D3 (supplement) 50 micrograms (mcg) 1
capsule PO daily prescribed 11/19/25; Dispensed
11/19/25 and 12/18/25.

Observation on 12/22/25 at 2:23 p.m. of Client
#2's medications reveated:

-Vyvanse 60 mg 1 PO every morning dispensed
11/21/25.

~Desvenlafaxine succinate 1 PO daily dispensed
12/15/25.

-Omeprazole 20 mg 1 PO daily dispensed
12/15/25.

-Vitamin D3 50 meg 1 PO daily dispensed
12/18/25.

Clonidine 0.1 mg 1 PO in the moming and 1 PO
in the evening dispensed 11/19/25.

-Trazodone 50 mg 1-1 1/2 tablets PO at HS
dispensed 11/19/25

-The following medications were not provided:
-Qelbree 200 mg .

Clonidine 0.3 mg.

-Lurasidone HCL 60 mg.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #2's MARs dated 10/1/25-12/22/25
revealed:

-October:

-Desvenlafaxine was documented as
administered at 6:30 am 10/1/25-10/31/25.
-Lurasidone was documented as administered at
5:00 pm 10/1/25-10/31/25.

-Clonidine 0.1 mg 1 tablet in the morning and
afternoon was documented as administered at
6:30 am and 1:00 pm except for 10/10/25 and
10/30/25 in which the 1:00 pm doses were left
blank.

-Clonidine 0.2 mg 1 tablet at HS was documented
Division of Health Service Regulation

STATE FORM

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

deuble~ ch

process for News Medicchan
Peers tend teanseripht

Ak

fy MARS. Which wil Face
Medicckior Or cca wil

be te port decumwnte: 1
and Pcbresced occurdia

lity With, currechur
te tckan as
oppropricke..
CU Adinin nists will
i} Neds Abeu
ree obsenionen
Q MARS audits
ily basis peorpe wish
seks, thon peo \
thereofter ee mininLiin,
of 3 months +8 ensure
Compliance,

8JRON Mf continuation sheet 11 of 52

PRINTED: 01/22/2026

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: ABUILDING: COMPLETED

MHL002-032 8. WING —________—— 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

Continued From page 11 il bs d 4 eninen ti

as administered 10/1/25-10/5/25, il
10/7/25-10/8/25, and 10/10/25-10/13/25. si issues

Clonidine 0.2 mg was marked with an "X" on an opal

10/6/25, 10/9/25, and 10/14/25-10/31/25. 3 tence | goumed) w 4
-Trazodone 1 tablet at HS was documented as \ A © 7
administered 10/1/25-10/31/25. va agh peTron 4

-Qelbree 200 mg 2 capsules daily at 1:00 pm was bi ny
documented as administered 10/1/25-10/9/25 dis a) pl ne ACTON 7

GEORGIE'S HELPING HAND

and 10/11/25/-10/30/25. Documentation on

10/10/25 was left blank, and entries on 10/30/25 Necessary *
and 10/31/25 were marked with a cross without

any accompanying explanation.

-Omeprazole was listed but left blank and not
documented as administered from Cuil f\ Aunist xh sey “4
10/1/25-10/31/25.

-Vyanse was documented as administered at al AN J j ll b 2 th
6:30 am from 10/1/25-10/9/25 and from Licesel

10/18/25-10/31/25. Entries from

10/10/25-10/17/25 were marked with an "X" res sible persons
without further explanation. an
-Vitamin D3 was listed with no specified Le lemen apn.
administration time and was not documented as rin

administered from 10/1/25-10/31/25. MOR u “4
-Dextroamphetamine (ADHD) 5 mg was listed Q

with instructions to take 1 tablet PO daily at 1:00

pm and was documented as administered

10/1/25-10/3/25, marked with an "X"

10/4/25-10/6/25, and left blank 10/7/25-10/31/25.

-November:

-Desventafaxine was documented as

administered at 6:30 am 11/1/25-11/29/25, and at

7:00 pm 11/30/25.

-Lurasidone was listed twice on the MAR. On one

page, the administration time was blank, and no

doses were documented as administered from

11/1/25-11/30/25. On another page, the

administration time was listed as 8:00 pm, with

doses documented as administered on

41/4/25-11/4/25 and left blank from

41/5/25-11/30/25.

Division of Health Service Regulation

STATE FORM. se99 QJRO11 {f continuation sheet 12 of 52

of

PRINTED: 01/22/2026
FORM APPROVED

‘STATEMENT OF DEFICIENCIES {X#) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL002-032 B. WING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

‘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)

GEORGIE'S HELPING HAND

Continued From page 12

-Clonidine 0.1 mg was listed twice on the MAR. Resp nges ty these

On one page, instructions for 1 tablet in the
morning and 1 tablet in the afternoon were LesueS ine Ney iously Addrassed

documented as administered from nf
41/1/25-11/19/25 at 6:30 am and at an additional the

illegible time which appeared to read "3X5." On in is Fepo ‘
another page, clonidine 0.1 mg was listed with
administration times of 6:30 am and 4:00 pm,

with doses documented as administered from
11/20/25-11/28/25. On 11/29/25, the 6:30 am
dose was documented as administered, and the
4:00 pm dose contained an entry consisting of a
circled mark without initials. On 11/30/25, a dose
was documented as administered at 7:00 am,

and the 4:00 pm dose was left blank.

-Clonidine 0.2 mg 4 tablet at HS was documented
as administered 11/1/25-11/3/25. On
11/4/25-11/10/25, the corresponding MAR entry
boxes were traced on the edges in ink without
initials or documentation in the boxes. No
administration was documented from
11/11/25-11/30/25, as the entries were {eft blank.
-Clonidine 0.3 mg was documented as
administered 11/20/25-11/30/25.

-Trazodone 1 tablet at HS was documented as.
administered 11/1/25-11/19/25. Trazodone 1 to 4
1/2 tablet at HS was documented as administered
11/20/25-11/30/25 and did not specify the number
of tablets administered for each dose.

-Qelbree 200 mg 1 capsule each morning was
documented as administered from
11/1/25-11/19/25 and left blank from
11/20/25-11/30/25.

-Qelbree 200 mg 1 capsule once daily at 1:00 pm
was left blank from 11/1/25-11/19/25 and
documented as administered 11/20/25-11/30/25.
~Omeprazole was listed twice on the MAR. On
one page the medication time slot was left blank,
and there was no documentation of
administration from 11/1/25-11/30/25. On a
Division of Health Service Regulation

STATE FORM 5800 8JROM If continuation sheet 13 of 52

PRINTED: 01/22/2026
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: COMPLETED

A. BUILDING:

MHL002-032 B. WING 01/12/2026

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
480 RADIO ROAD
‘TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

Continued From page 13

separate page, omeprazole was listed with Responses 4y these.

instructions to take 1 capsule once daily, with two ¢ ‘| OSs
administration times specified (6:30 am and 7:00 sues Prev ovs ly Add

am). Documentation indicated the medication « . et
was not administered at either time from Ww this report
11/1/25-11/19/25, administered at 6:30 am on

11/20/25-11/21/25 and 41/23/25-11/29/25, and

administered at 7:00 am on 11/22/25 and

11/30/25.

-Vyvanse was listed twice on the MAR. On one

page, Vyvanse was listed with a specified

administration time of 6:30 am and documented

as administered from 11/1/25-11/19/25.

Documentation was left blank from

11/20/25-11/30/25. On a separate page, Vyvanse

was listed with instructions to take 1 capsule once

daily, with two administration times specified

(6:30 am and 7:00 am). Documentation on this

page was left blank 11/1/25-11/19/25 and

documented as administered at 6:30 am

11/20/25-11/29/25 and at 7:00 am on 11/30/25.

The 6:30 am entry for 11/30/25 had been initialed

by staff and subsequently scribbled out with black

ink, without explanation.

-Vitamin D3 was listed twice on the MAR. On one

page, Vitamin D3 was listed without a specified

administration time and was marked with an "X"

from 11/1/25-11/19/25. Documentation was left

blank from 11/20/25-11/30/25. On a separate

page, Vitamin D3 was listed with instructions to

take 1 capsule once daily, with two administration

times specified (6:30 am and 7:00 am).

Documentation on this page indicated the

medication was not administered at either time

from 11/1/25-11/19/25 and was documented as

administered at 6:30 am 11/20/25-11/21/25 and

11/23/25-11/29/25, and at 7:00 am 11/22/25 and

11/30/25.

-Dextroamphetamine was not listed on the MAR.

-December:
Division of Health Service Regulation
STATE FORM Ld aJRON Mcontinuation sheet 14 of 52

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED

MHL002-032 8. WING ____—_______ 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

‘SUMMARY STATEMENT OF OEFICIENCIES 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)

GEORGIE'S HELPING HAND

Continued From page 14

-Desvenlafaxine was documented as ponses ts thes zu
administered at 6:30 am 12/1/25-12/11/25, t

12/13/25-12/14/25, and 12/16/25-12/19/25. It was ugshes fae t ously Addr es oA
documented as administered at 8:00 am on
12/15/25 and 12/20/25-12/22/25. Desvenlafaxine in ds repeat ‘
was not documented as administered on
12/12/25.

-Lurasidone was listed with no administration
time, and doses were not documented as
administered from 12/1/25-12/22/25.

Clonidine 0.1 mg was listed once with
instructions to administer 1 tablet in the moming
and 1 tablet in the evening. The administration
times were listed as 6:30 am, 4:00 pm and 8:00
am. Doses were documented as administered as
follows: On 12/1/25-12/4/25, 12/7/25-12/41/25,
and 12/16/25 at 6:30 am and 4:00 pm. On
12/5/25 at 4:00 pm only (no am dose). On
12/6/25, 12/12/25-12/14/25, and
12/17/25-12/19/25 at 6:30 am only (no pm
doses). On 12/20/25 and 12/22/25 at 8:00 am
only (no pm doses). On 12/21/25 at 4:00 pm and
8:00 am. On 12/15/25 the 6:30 am slot was left
blank, the 4:00 pm entry contained a circled mark
without initials, and the 8:00 am dose was
initialed as administered.

-Cionidine 0.3 mg was documented as
administered 12/1/25-12/19/25, teft blank on
12/20/25, and marked with an "X" on 12/21/25.
-Trazodone 1 to 1 1/2 tablet at HS was
documented as administered 12/1//25-12/21/25
and did not specify the number of tablets
administered for each dose.

-Qelbree 200 mg 1 capsule once daily at 1:00 pm
was documented as administered
12/1/25-12/21125.

-Omeprazole was listed with instructions to take 1
capsule once daily, with two administration times
specified (6:30 am and 8:00 am). The medication
was documented as administered at 6:30 am
Division of Health Service Regulation

STATE FORM 899 8URO11 If continuation sheet 15 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A.BUILDING: COMPLETED

MHL002-032 8. WING 01/12/2026

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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) (ROSS-REFERENCED TO THE APPROPRIATE.
DEFICIENCY)

GEORGIE'S HELPING HAND

V 118] Continued From page 15

from 12/1/25-12/14/25 and from Resp wnses +6 these
12/16/25-12/19/25 and documented as
administered at 8:00 am on 12/15/25 and from vet feovi b busly

12/20/25-12/22/25.

-Vyvanse was listed once with instructions to take Addressad t ur fhis Feps a
1 capsule in the moming, with two administration
times specified (6:30 am and 8:00 am). Vyvanse
was documented as administered at 6:30 am
42/9/25-12/11/25, 12/13/25-12/14/25, and
12/16/25-12/19/25. Documented as administered
at 8:00 am on 12/15/25 and 12/20/25-12/21/25.
Documentation for 12/12/25 was left blank with
no record of administration.

-Vitamin D3 was listed with instructions to take 1
capsule once daily with two specified
administration times (6:30 am and 8:00 am).
Vitamin D3 was documented as administered at
6:30 am 12/1/25-12/11/25, 12/13/25-12/14/25,
and 12/16/25-12/19/25, and documented as
administered at 8:00 am 12/15/25 and
12/20/25-12/22/25.

-Dextroamphetamine was not listed on the MAR.

Review on 12/22/25 of Client #3's record
revealed:

-No physician's order for any administered
medications,

Review on 12/23/25 of a dispense sheet dated
8/1/25-12/23/25 obtained by DHSR surveyors on
12/23/25 from the local pharmacy which
dispensed Client #3's medications revealed:
-Desmopressin (bedwetting) 0.2 mg 1 tablet PO
at HS prescribed 9/19/25; Dispensed 9/21/25.
~Desmopressin 0.2 mg 4 tablets PO at HS
prescribed 10/16/25; Dispensed 10/16/25.
-Carbamazepine (seizures) 100 mg Chew and
swallow 2 tablets PO at 8:00 am and 2 tablets at
8:00 pm prescribed 9/19/25; Dispensed 10/30/25.
-Carbamazepine 100 mg chew and swallow 2
Division of Health Service Regulation
‘STATE FORM on99 aJROM1 H continuation sheet 16 of 52

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING:

MHL002-032 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
480 RADIO ROAD
TAYLORSVILLE, NC 28681

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

GEORGIE’S HELPING HAND

Continued From page 16

tablets PO BID prescribed 9/22/25 and 12/12/25;

Dispensed 9/22/25 and 12/15/25. : (

-Concerta (ADHD) 27 mg 2 tablet PO in the Sues Provieus 4

moming (Do Not Exceed 1 per 24 hours) ’ . +,
prescribed 9/22/25; Dispensed 9/22/25. Addressed vn thi g fapoe!
-Concerta 36 mg 1 tablet PO in the moming (Do

Not Exceed 1 per 24 hours) prescribed 10/16/25;

Dispensed 10/16/25 and 12/2/25.

-Melatonin (insomnia) 3 mg Dissolve 1-2 tablets

PO at HS prescribed 9/22/25; Dispensed 9/22/25.

Observation on 12/22/25 at 2:49 p.m. of Client
#3's medications revealed:

-Desmopressin 0.2 mg 4 tablets PO at HS
dispensed 10/16/25.

-Methylphenidate ER 36 mg 1 PO in the moming
dispensed 12/2/25.

-Fluticasone 27.5 mcg nasal spray 1 ml spray into
each nostril daily dispensed 3/28/25.

-The following medications were not provided:
-Carbamazepine 100 mg.

-Melatonin 3 mg.

-Docusate Sodium 50 mg.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #3's MARs dated 10/1/25-12/22/25
revealed:

-Fluticasone nasal spray (allergy symptoms) 27.5
mcg was listed on the October 2025, November
2025, and December 2025 MARs with
instructions to take 1 milliliter (ml) of nasal spray
daily and was not documented as administered
from 10/1/25-12/22/25.

-Docusate sodium (constipation) 50 mg was
listed on the October 2025 and November 2025
MARs with instructions to take 1 capsule PO BID
at 8:00 am and 8:00 pm and was not documented
as administered for either dose from
10/4/25-11/30/25.

-Carbamazepine had written instructions on the
Division of Health Service Regulation

STATE FORM om 8JRO11 {f continuation sheet 17 of §2

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILOING:

MHL002-032 B. WING.

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

Continued From page 17

October 2025, November 2025 and December Res OngesS fs thes @
2025 MARs to take 2 tablets “twice daily (8am, “t :

8pm)" but had specified administration times for “ . ¢
8:00 am, 6:30 am, and 8:00 pm. Ssues fravious ly

Cxbetiabesine was left blank for the 8:00 am Adlrescecl in this Rep od

dose from 10/1/25-10/31/25. Carbamazepine was
documented as administered at 6:30 am and 8:00
pm on 10/1/25-10/8/25, 10/10/25-10/11/25, and
10/13/25-10/27/25. On 10/9/25, the 6:30 am dose
was documented as administered, and the 8:00
pm dose was left blank. On 10/12/25 and
10/31/25, the 6:30 am dose was documented as
administered, and the 8:00 pm dose was marked
with an “X." From 10/28/25-10/30/25, both the
6:30 am and 8:00 pm doses were marked with an
nye

-Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 10/1/25-10/31/25.
-Concerta 27 mg was documented administered
10/1/25-10/19/25 and marked with an "X" from
40/20/25-10/31/25.

-Concerta (methylphenidate) 36 mg with
instructions was blacked out with ink from
10/1/25-10/19/25 and documented as
administered at 6:30 am 10/20/25-10/31/25.
Melatonin 1-2 tablets at HS was documented as
administered 10/1/25-10/31/25 but the number of
tablets administered were not specified.
November:

-Carbamazepine was documented as
administered at 8:00 am and 8:00 pm on
44/1/25-11/2/25 and 11/16/25. it was documented
at 6:30 am and 8:00 pm from 11/3/25-11/7/25,
11/10/25-11/14/25, 14/17/25-11/21/25, and
11/24/25-11/25/25. On 11/8/25 and 11/9/25, the
8:00 am and 8:00 pm doses were documented as
administered, and the 6:30 am doses were
marked with circles over what appeared to be
Division of Health Service Regulation
STATE FORM nee 8JRO11

Wf continuation sheet 18 of 52

Division of Heaith Service Regulation

‘STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

PRINTED; 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

‘COMPLETE

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 18

whited-out initials. On 11/15/25, the 8:00 am and
8:00 pm doses were documented as
administered, and the 6:30 am doses were left
blank, and the 8:00 pm doses were marked with
an "X." On 11/27/25, the 8:00 am dose was
documented as administered, and the 6:30 am
and 8:00 pm doses were left blank. On 11/28/25,
the 8:00 pm dose was documented as
administered, and the 6:30 am and 8:00 am
doses were left blank.

-Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 11/1/25-11/30/25.
~Concerta (methylphenidate) 36 mg with
instructions "DO NOT EXCEED 1 PER 24
HOURS' was blacked out with ink from
10/1/25-10/19/25, documented as administered
at 6:30 am 11/1/25-11/15/25, at 8:00 am 11/16/25
(22 % hours from previous dose), and at 6:30 am
41/17/25-114/22/25, then marked with an "X" from
11/23/25-11/30/25.

-Melatonin 1-2 tablets at HS was documented as
administered 11/1/25-11/26 and 11/28/25 but the
number of tablets administered were not
specified. Melatonin was marked with an "X" on
11/29/25-11/30/25 and was left blank on 11/27/25.
December:

-Carbamazepine doses were documented as
follows: On 12/1/25, an "R" was documented at
8:00 am, the 6:30 am dose was left blank, and
the 8:00 pm dose was documented as
administered. On 12/2/25, the 6:30 am dose was
documented as administered, and the 8:00 am
and 8:00 pm doses were left blank. On 12/3/25,
the 6:30 am and 8:00 am doses were left blank,
and the 8:00 pm dose was marked with an "R”
and initials without further explanation. On
12/4/25, the 8:00 am dose was left blank, and the
6:30 am and 8:00 pm doses were marked with an
"R" and initials. On 12/5/25, the 8:00 am and 8:00
Division of Heaith Service Regulation
STATE FORM

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

Responses ts these

Tesues Preyi ously

Addressed ia this fepoct-

8JRO11 Ifcontinuation sheet 19 of 62

PRINTED: 01/22/2026
FORM APPROVED

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

MHL002-032 8. WING.

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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) GROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

GEORGIE'S HELPING HAND

Continued From page 19

pm doses were documented as administered, Responses ts thes aq

and the 6:30 am dose contained scribbled-out

initials. On 12/6/25, the 6:30 am and 8:00 am sSu es f, vid us \
doses were marked with an °X," and the 8:00 pm T w& J

dose was left blank. On 12/7/25, the 8:00 am and A duress A in Shis Fapor t.
8:00 pm doses were left blank, and the 6:30 am
dose was marked with an “R” and initials.
Carbamazepine was documented as
administered at 6:30 am and 8:00 pm on 12/8/25,
12/10/25, and 12/11/25. On 12/9/25, the 6:30 am
and 8:00 pm doses were documented as.
administered, and the 8:00 am dose was marked
with an "R" and initials. On 12/12/25, the 6:30 am
dose was documented as administered, the 8:00
am dose was left blank, and the 8:00 pm dose
was marked with a "?." From 12/13/25 through
12/6/25, on 12/18/25 through 12/19/25, and on
12/21/25, doses were documented as
administered at 8:00 am and 8:00 pm. On
12/17/28, the 6:30 am and 8:00 pm doses were
documented as administered. On 12/20/25, all
doses were left blank. On 12/22/25, the 8:00 am
dose was documented as administered.
Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 12/1/25-12/19/25 and
12/21/25. Administration was not documented for
12/20/25 as the entry was left blank.
-Methylphenidate 36 mg was listed with specified
administration times of 6:30 am and 8:00 am.
Methylphenidate was left blank on
12/1/25-12/2/25 and 12/20/25. It was documented
as administered at 6:30 am on 12/3/25-12/4/25,
12/6/25-12/8/25, 12/11/25-12/12/25, and
12/16/25-12/17/25. It was documented as
administered at 8:00 am on 12/5/25,
12/9/25-12/10/25, 12/13/25-12/15/25,
412/18/25-12/19/25, and 12/21/25-12/22/25.
-Melatonin 1-2 tablets at HS was left blank
12/1/25-12/22125.

Division of Health Service Regulation
STATE FORM 6899 8URONI \fcontinuation sheet 20 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER: A.BUILDING: COMPLETED

MHL002-032 8. WING ______!____ 01/12/2026
NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE.

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE’S HELPING HAND

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

V 118] Continued From page 20

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

~"| don't have medication certification. I'm not
trained in that. Am | in trouble?"

-He initialed and circled his initials on the MAR to
indicate the medication was administered.

-"We (staff) are taught to not use white out on the
MAR."

Interviews on 12/23/25 and 1/8/26 with the
Director/Licensee revealed:

-The Program Director did have medication
administration training by a Registered Nurse
(RN), "I don't know why he would say that (he
didn't have training).”

-On 12/22/25 the Program Director "didn't give
you all of the (clients') medications. The rest is
kept in a different cabinet drawer."

-The Executive Director/Licensee transcribed the
new MARs each month, reviewed them at the
end of the month and was responsible for
obtaining the physician's orders.

Interview on 1/6/26 with the Executive
Director/Licensee revealed:
-He listed all the medications on the MARs for
each client every month.
-He and the facility RN reviewed the MARs for
accuracy at the end of each month.
-"I didn’t know if you circle it (the box on the MAR)
it means they didn't receive their medications and
| didn't know that just a circle did that. There's
nothing down there (bottom of MAR) telling what
an "O" is and what an "R” is. | found out when you
(DHSR surveyors) came here and then the
(facility) nurse came and said | shouldn't circle it.
It was an unknowledgeable mistake."
~"I should have let you (DHSR surveyors) in the
Office (on 12/22/25). Some of the medications
Division of Health Servica Regulation
STATE FORM

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

Kin
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sent i by B 8

8JRO11 Mfcontinuation sheet 21 of 52

STATEMENT OF DEFICIENCIES. (X41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE’S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 21

were on the right-hand side and you have to go
on the left hand side to get those medications and
when he (the Program Director) brought it out he
forgot to take the boxes out and that's rare but
they (clients) get their medications.”

-An 'X' on the MAR meant the client did not
teceive the medication, " ...that means they didn't
get it ...It's a careless mistake, nothing behind it
..but you can't do that.”

-The physician's orders were sent directly to the
pharmacy. "We don't touch it (physician's orders)
...We don't have copies (of physician's orders) in
the facility.”

~He picked up the medications from the
pharmacy.

Due to the failure to accurately document
medication administration, it could not be
determined if clients received their medications
as ordered by the physician.

Review on 12/23/25 of the Plan of Protection
dated 12/23/25 written by the Director/Licensee
revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
GHH (Georgie's Helping Hand) Administrative
Staff will immediately review all Physicians’
Medication Orders for all consumers (clients) in
our care, as well as contact the prescribing
physicians to request a listing and review of the
medication profiles for each of the consumers; to
assure we have the most current and accurate
listings of the consumers prescribed medications.
GHH Adninistrators will have a Staff Meeting on
this date to review the MARS document for
omissions; missing documentation to be
addressed with late entries noted.

Medication administration to be temporarily
restricted to Staff with verified medication

Division of Health Service Regulation.
‘STATE FORM

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

Sal al

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6T Norrafives 49

sf

aJRO11 tf continuation sheet 22 of 52

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

MHL002-032
NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 22

management competency until corrective training
is completed.

GHH Administrator have contacted our
Registered Nurse Medication Management
Trainer today, 12/23/2025, who will avail herself
to conduct a Mandatory Medication Management
Training, her earliest available date being
Monday, 12/29/2025 or an immediate date
thereafter.

Describe your plans to make sure the above
happens.

Discrepancies identified are to be acknowledged
and corrected immediately for future references.
Updated, verified medication lists to be placed in
the consumers’ records and medication
administration area. GHH Staff will undergo
immediate training today on how to property fill
out the MARS document, as well as the required
follow-up documents necessary to be submitted
in the event that medications are not
administered as expected, which would include
consumer refusals, out of the GH (group home),
and any other situations that may apply.

Daily review audits of the MARS documents to be
conducted by GHH Administrators; Executive
Director (Licensee) and Director (Licensee).”

This deficiency constitutes a re-cited deficiency.

The facility served clients with diagnoses that
included but were not limited to Oppositional!
Defiant Disorder, Attention-Deficit Hyperactivity
Disorder, Autism Spectrum Disorder, Anxiety
Disorder, Conduct Disorder, and Disruptive Mood
Dysregulation Disorder. Client #1 had at least 5
missing physician's orders. Client #2 and Client
#3 had no documented physician's orders for any
medications administered. For Client #1, at least
94 medication doses were documented as
administered without a corresponding physician's
Division of Health Service Regulation

STATE FORM

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

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BJRO11 continuation sheet 23 of 52

STATEMENT OF DEFICIENCIES: (X41) PROVIDERISUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002.032
NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 23

order and at least 72 physician-ordered doses of
medication lacked documentation of
administration. For Client #2, at least 1,200
medication doses were documented as
administered without a corresponding physician's
order and at least 210 doses were marked with
an "X," circles without initials, altered entries, or
blank fields were present on Client #2's MARs.
These doses included psychotropics, stimulants,
and supplement medications. For Client #3, at
least 980 medication doses were documented as
administered without a corresponding physician's
order and at least at least 265 medication doses
were marked with an "X," "R,” "?," crossed-out
entry, or left blank. The facility did not maintain
documentation to indicate a physician or
pharmacist had been notified of medication
errors. Across all three clients, the facility
documented at least 2,274 medication doses
administered without physician orders and at
least 547 missed or undocumented doses from
10/1/25 through 12/22/25. This deficiency
constitutes a Type A1 rule violation for serious
neglect and must be corrected within 23 days.

27G .0209 (H) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

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

Division of Health Service Regulation
STATE FORM

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

Most recent Peeseribi
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BJRO11 If continuation sheet 24 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA (X2} MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ABUILDING:

MHL002-032 B. WING.

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE

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

Nedication Adminis hei

ddressed in th
issues 18)

GEORGIE'S HELPING HAND

Continued From page 24

This Rule is not met as evidenced by:

facility failed to ensure drug administration errors
were reported immediately to a physician or
pharmacist for 3 of 3 audited clients (Clients #1,
#2 and #3). The findings are:

Based on record reviews and interviews, the See fy es a I~2

Review on 12/23/25 and 1/5/26 of facility records
between 10/1/25 and 1/5/26 requested from the
DirectoriLicensee and the Executive
DirectoriLicensee revealed:

-No documentation that medication errors had
been reported to a physician or pharmacist.

Review on 12/22/25 of Client #1's record
revealed:

-Date of Admission 8/15/25.

-15 years old.

-Diagnoses of Oppositional Defiant Disorder
{ODD), Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorder and Anxiety
Disorder.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #1's MARs dated 10/1/25-12/22/25
reveated the following medications had dates that
were documented with an *X", left blank, or
circled:

-Cetirizine HCL (allergies) 10 mg - between
10/1/25 and 11/5/25 - 35 doses.

-Montelukast Sodium (asthma) 10 mg - between
10/1/25 and 12/22/25 - 54 doses.

-Qelbree ER (ADHD) 200 mg - 12/22/25 - 1 dose.
-Metformin HCL (prediabetes) 500 mg - on
11/30/25 and 12/21/25 - 2 doses.

~Fluoxetine HCL (depression) 10 mg - between
Division of Health Service Regulation

STATE FORM. Saad 8JRON1 H continuation sheet 25 of 52

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

MHL002-032
NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 25

12/16/25 - 12/31/25 - 16 doses.

-Aripiprazole (agitation) 5 mg - between 10/1/25 -
10/31/25 - 31 doses.

-Guanfacine (impulsivity/ODD) 4 mg - between
10/1/25 - 10/31/25 - 31 doses.

-Oxcarbazepine (ADHD) 300 mg - between
10/1/25 - 12/22/25 - 83 doses.

-Levocetirizine (allergies) 5 mg - on 10/1/25,
10/2/25 and 12/20/25 - 3 doses.

Fluoxetine HCL 20 mg - on 11/6/25 and between
41/30/25 and 12/22/25 - 26 doses.

Review on 12/22/25 of Client #2’s record
revealed:

-Date of Admission 9/17/25.

-14 years old.

-Diagnoses of ODD and ADHD.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #2's MARs dated 10/1/25-12/22/25
revealed the following medications had dates that
were documented with an "X", left blank, outlined
or circled:

-Desvenlafaxine succinate ER (depression) 100
mg - 12/12/25 - 1 dose.

-Lurasidone (mood disorder) 60 mg - between
11/5/25 - 11/30/25, and 12/1/25 - 12/22/25 - 47
doses.

-Clonidine (ADHD) 0.1 mg - 1 tablet in the am
and 1 tablet in the pm - 11/29/25, and 12/15/25
am and pm - 3 doses.

~Clonidine 0.2 mg -1 tablet at HS - 10/6/25,
10/9/25, between 10/14/25 - 10/31/25, 11/4/25 -
11/30/25, 12/20/25 and 12/21/25 - 49 doses.
-Clonidine 0.3 mg 1 tabiet at HS - 12/20/25 and
12/21/25 - 2 doses.

-Qelbree ER 200 mg 1 capsule in am - between
11/20/25 - 11/30/25 - 10 doses.

-Qelbree ER 200 mg 1 capsule at 1:00 pm -
between 11/1/25 - 11/19/25 - 19 doses.

Division of Health Service Regulation
STATE FORM

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

issues addressed tn this
Fe port (Vis)
See Pages 21-24

8JRO11 Mcontinuation sheet 26 of 52

PRINTED: 01/22/2026
FORM APPROVED

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

MHL002-032 haddabad

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

Continued From page 26

€ ron 7

-Qelbree ER 200 mg 2 capsules at 1:00 pm - Me di ¢ afi ow Adm nu stach
10/10/25, 10/30/25, 10/31/25 - 3 doses. . A .
-Vyvanse (ADHD) 60 mg - between 10/10/25 - LsSued addr. aS od Ut thi 5
10/17/25, 11/1/25 - 11/19/25, 12/12/25 - 27 doses. \
Vitamin D3 (supplement) 50 micrograms - Fepoet ( Vu,
between 10/1/25 - 10/31/25, 14/1/25 - 11/19/25 - dl~2 f
50 doses. e ~ ‘
-Dextroamphetamine (ADHD) 5 mg - between S ee fe ag v

10/4/25 - 10/31/25 - 28 doses.

Review on 12/22/25 of Client #3's record
revealed:

~-Date of Admission 9/13/25,

-14 years old.

-Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #3's MARs dated 10/1/25-12/22/25
revealed the following medications had dates that
were documented with an "X", "R”, left blank, or
circled:

-Desmopressin (bedwetting) 0.2 mg - 12/20/25 -
1 dose.

-Carbamazepine (seizures) 100 mg - am -
10/28/25 - 10/30/25, 11/28/25, 12/1/25, 12/3/25,
12/4/25, 12/6/25, 12/7/25, 12/20/25 for a total of 9
doses; pm - 10/9/25, 10/12/25, 10/28/25 -
10/31/25, 11/15/25, 11/27/25, 12/2/25, 12/3/25,
12/4/25, 12/6/25, 12/7/25, 12/12/25, 12/20/25 - a
total of 15 doses.

Concerta (ADHD) 36 mg - between 10/1/25 -
10/19/25, 11/23/25 - 11/30/25 - 27 doses.
-Melatonin (insomnia) 3 mg - 11/27/25, 11/29/25,
11/30/25, between 12/1/25 - 12/22/25 - 25 doses.
-Fluticasone nasal spray (allergy symptoms) 27.5
meg - between 10/1/25 - 12/22/25 - 83 doses.
-Docusate sodium (constipation) 50 mg - am and
pm - between 10/1/25 - 11/30/25 - 122 doses.

Division of Health Service Regulation
STATE FORM cad 8JROM ‘fcontinuation sheet 27 of 52

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

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

MHL002-032 8. WING 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681
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)

Continued From page 27 dé on ang 6 :
Interviews on 12/22/25, 1/5/26 and 1/8/26 with the Ne HeayiOn Advu ag trotion.

Program Director revealed: issues addr ess ed in his

-His duties included administration of medications V
to the clients. et t )
-If a client refused their medications "we are to Fepo < | §

indicate it on the back of the MAR but we were
doing an ‘X’ or just teaving it blank.” See foges 4) ~ay ‘

Interview on 1/6/26 with the Qualified
Professional revealed:

~"I just do (administer) the medications.
[Executive Director/Licensee] is over it (MARs)
and talks over it with the nurse ...again that is not
my forte."

-Reported medication errors to the Executive
Director/Licensee, "it's verbal and written. It's
written on the MARs on the opposite side there's
a place if there is an error that occurs, we put it
on the back ...”

GEORGIE'S HELPING HAND

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-An 'X' on the MAR meant the client did not
receive the medication. "If there's blanks, | want
to find out why there's blanks and | look back and
see who was on shift and ask why there's blanks
on the medication and there's a big discussion.
You might have a sheet (MAR) but they aren't
getting that medication anymore. | need to get
behind that and make sure | am getting letters
(physician's orders) stating that medication has
been discontinued.”

-If there's an error that has been made "I will
contact the (client's physician's) office, the
(client's physician's) nurse and let her know and
she will get in touch with the doctor (client's
physician) and get back to me.”

-"No,” there was no medication errors made in
the past 3 months (October, November and
December 2025).

Division of Health Service Regulation
STATE FORM se89 BURON1 Mf continuation sheet 28 of $2

QTATEMENT OF DEFICIENCIES, (01) PROVIDER/SUPPLIER/CLIA
ANQ PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER:

GEORGIE'S HELPING HAND aenini

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE.

TAYLORSVILLE, NC 28681

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

Continued From page 28

This deficiency is cross-referenced into 10A
NCAC 27G.0209 Medication Requirements
(V118) for a Type A1 rule violation and must be
corrected within 23 days.

27G .1701 Residential Tx. Child/Ado! - Scope

410A NCAC 27G .1701 SCOPE

(a) A residential treatment staff secure facility for
children or adolescents is one that is a
free-standing residential facility that provides
intensive, active therapeutic treatment and
interventions within a system of care approach. It
shall not be the primary residence of an individual
who is not a client of the facility.

(b) Staff secure means staff are required to be
awake during client sleep hours and supervision
shall be continuous as set forth in Rule .1704 of
this Section.

(c) The population served shall be children or
adolescents who have a primary diagnosis of
mental illness, emotional disturbance or
substance-related disorders; and may also have
co-occurring disorders including developmental
disabilities. These children or adolescents shail
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:

(1) removal from home to a
community-based residential setting in order to
facilitate treatment; and

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

(1) include individualized supervision and
structure of daily living;

(2) minimize the occurrence of behaviors
related to functional deficits;

(3) ensure safety and deescalate out of

Division of Health Service Regulation
STATE FORM

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

a Ministers sul Rit,

@. U
ovens aa ae ty

igus!
assurance echt et ts)
meet or ine

ma eam *

ity
bei S ie arate

hel at 10

& Manage ote ent
Response ond fs as

8JRO11 ff continuation sheet 29 of 52

(X1) PROVIDERISUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-032

NAME OF PROVIDER OR SUPPLIER:

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY

COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE.
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 29

contro! behaviors including frequent crisis
management with or without physical restraint;
(4) assist the chiid or adolescent in the
acquisition of adaptive functioning in self-control,
communication, social and recreational skills; and
(5) support the child or adolescent in
gaining the skills needed to step-down to a less
intensive treatment setting.

(f) The residential treatment staff secure facility
shall coordinate with other individuals and
agencies within the child or adolescent's system
of care.

This Rule is not met as evidenced by:

Based on observation, record reviews and
interviews, the facility failed to operate within the
scope of their license to include individualized
supervision and structure of daily living, ensure
safety, assist in the acquisition of adaptive
functioning, and support in gaining skills needed
to step-down to a less intensive treatment setting
and failed to ensure an individuat who was not a
client did not maintain their primary residence at
the facility. The findings are:

Cross Reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112): Based on record reviews
and interviews, the facility failed to develop and
implement treatment plans based on client needs
Division of Health Service Regulation

STATE FORM

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

well ag provide alinies
and behavioral up peut
Services Gppeoprae
Served:
He pope Se CiNdR

7 ins OF Fe
os edie oot GEE

8URO11 {continuation sheet 30 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

5B. WING.

MHL002.032

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

01/12/2026

GEORGIE'S HELPING HAND

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

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

Continued From page 30

within 30 days of admission for 3 of 3 audited
clients (Clients #1, #2 and #3).

Cross Reference: 10A NCAC 276.1702
Requirements of Qualified Professionals (V294):
Based on record reviews and interviews, the
Qualified Professional (QP) failed to perform
clinical and administrative responsibilities at a
minimum to include the supervision of the
Associate Professional (AP), oversight of
emergencies, provision of direct
psychoeducational services, participation and
coordination of treatment plans, and provision of
case management functions.

Cross Reference: 10A NCAC 27G.1703
Requirements for Associate Professionals
(V295): Based on record reviews and interviews,
the facility failed to employ a full-time Associate
Professional (AP) who ensured management of
the daily operations of the facility, supervision of
paraprofessionals, and participation in service
planning meetings.

Cross Reference: 10A NCAC 27G.1704 Minimum
Staffing Requirements (V296): Based on
observation, record reviews and interviews, the
facility failed to ensure the required minimum
number of 2 direct care staff for 1 to 4 clients
were present.

Review on 12/30/25 of the Program Director's
record revealed:

-Date of Hire: 7/6/21.

-North Carolina (NC) driver's license listed the
facility address as his residence.

desicieney en
Pr6 cael vital on (ih
~The Program Director "sleeps (at the facility) on

ipa base”

STATE FORM ome: 8JRO11 If continuation sheet 34 of 52

Interviews on 12/22/25 and 1/5/26 with Client #1
revealed:

PRINTED: 01/22/2026
FORM APPROVED

Division of Health Service Re

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

MHL002-032 8. WING 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

V 293) Continued From page 31

. ot bei af GH
the couch. Ne a ee ctemen
is Page
ssProgram Direct] ters hor (ect nas tp the Lepr On This Pag

e .

much" (¥293) and on Page
this repo (1293

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the 33 oF 1S Fepo

Program Director revealed:

-"I work ail shifts. | am here (facility) pretty much

around the clock. | am in and out but here every

shift. | don't live here. | have another home. | just

use this address on my license. My address is in

(another state). | am a traveler ...1 have no home

in North Carolina. | don't need sleep ...just kind of

rest ...| sleep in the office, there's a recliner

...When we work, 1 (staff) is allowed to sleep ...1

(staff) awake and 1 asleep."

Review on 1/9/26 of the Plan of Protection dated
1/9/26 written by the Director/Licensee revealed:
"What immediate action will the facility take to
| ensure the safety of the consumers in your care?
(V293) GHH (Georgie's Helping Hand) current
Program Director does spend a great amount of

time at the Group Home, fulfilling his duties, as
well as filling in as needed when there's a
shortage of staff. However, the facllty is not his
place of domicile.

(V294) GHH Administrative Staff will meet with
current QP immediately, at least by 01/10/2026,
to review, explain and reiterate the duties and
tesponsibilities of the QP position for which he
was hired for.

(V295) GHH Administrative Staff will identify
and/or hire an Associate Professional, as
required, to fulfill their duties in this position,
which would include their participation and input
with the Residents' Service (treatment) Plans and
Staff Meetings, as well as addressing the daily
operation of the facility, and the supervision of
Division of Health Service Regulation
STATE FORM ease BUROM

If continuation sheet 32 of 52

PRINTED: 01/22/2026
FORM APPROVED

Division of Health Service Regulation

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

MHL002-032 B. WING 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

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

GEORGIE'S HELPING HAND

Continued From page 32

Direct Support Staff.

(V296) GHH Administrators will ensure that at
feast the Minimum Staff Ratio is satisfied on all
shifts going forward by scheduling Staff to work
and provide coverage for the shifts accordingly.
({V112) GHH do have Treatment Plans for all
current Residents. Even though all were not
initially presented to the Surveyors upon request,
they were later produced as evidence that these
documents had been prepared and are available.
Describe your plans to make sure the above
happens.

(V293) Program Director does have a separate
residency in the State of North Carolina, which
has been confirmed by GHH Administrators.
Program Director will obtain a new ID
(identification), confirming his current NC
residence.

(V294) GHH Administrators will get the necessary
feedback from the QP, after having a meeting
with him to assure that he has a full
understanding and is still willing and capable of
performing the duties and responsibilities of the
QP Position. We will have the QP sign a new job
description form to review his rales and
responsibilities. QP will be place on a
Performance Improvement Plan as well.

(V295) GHH Administrators will offer an intemal
hire for the AP position. In the event it cannot be
filled internally, we will post the position and seek
an extemal hire.

296) GHH Administrators will maintain a log
which will identify and indicate the staff member's
time in and time out for the clinical day, thereby
maintaining at least two staff members at the
facility at all times.

(V112) GHH Administrators will make sure that all
the Residents’ (clients') Treatment Plans are kept
in their folders, or at least on-site to be readily
available if necessary.”

Division of Health Service Regulation
STATE FORM e299 8JRO11 continuation sheet 33 of 52

Division of Health Service Regulation

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

MHL002-032
NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

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

Continued From page 33

Clients served by the facility were adolescents
who had mental health diagnoses including but
not limited to Oppositional Defiant Disorder,
Attention-Deficit Hyperactivity Disorder, Autism
Spectrum Disorder, Anxiety Disorder, Conduct
Disorder and Disruptive Mood Dysregulation
Disorder. The facility did not ensure the Program
Director did not maintain their primary residence
at the facility. The Program Director routinely
stayed overnight and used the facility address as
his residence. Client #1, Client #2 and Client #3
did not have individualized treatment plans within
30 days of admission and treatment strategies
were not documented or implemented based on
assessed client needs. The Qualified
Professional did not fulfill required clinical and
administrative responsibilities, including
supervision of staff, participation in treatment
planning, coordination of services, emergency
oversight, and case management. The facility did
not employ an Associate Professional responsible
for daily operations, supervision of
Paraprofessionals, and participation in service
planning meetings. The facility did not maintain
required minimum staffing ratios, as fewer than
two direct care staff were present which limited
supervision and support.

This deficiency constitutes a Type B rule violation
which is detrimental to the health, safety and
welfare of the clients and must be corrected
within 45 days.

27G .1702 Residential Tx. Child/Adol -Req. for Q
P

JOA NCAC 27G 1702. =REQUIREMENTS OF
QUALIFIED PROFESSIONALS

Division of Health Service Regulation
STATE FORM.

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

’ $ ent on
“hye HESS Ya12)

fee | Sfafen ert . upcdin
je a rei i;
ar ind
basen 35 -3b (V2)

Te ment re ing
Aa th

aJURON If continuation sheet 34 of §2

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES. (X1) PROVIDERISUPPLIERICLIA

(2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHL002-032 8. WING 01/12/2026
NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

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

294] Continued From page 34

(a) Each facility shall utilize at least one direct
care staff who meets the requirements of a
qualified professional as set forth in 410A NCAC
27G .0104(18). In addition, this qualified
professional shall have two years of direct client
care experience.

(b) For each facility of five or less beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
10 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and present in
the facility.

(c) For each facility of six or more beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
32 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and present in
the facility.

(d) The governing body responsible for each
facility shall develop and implement written
poticies that specify the clinical and administrative
responsibilities of its qualified professional(s). At
a minimum these policies shail include:

(1) supervision of ifs associate
professional(s) as set forth in Rule .1703 of this
Section;

(2) oversight of emergencies;

(3) provision of direct psychoeducational
services to children or adolescents;

(4) participation in treatment planning
meetings;

(5) coordination of each child or
adolescent's treatment plan; and

(6) provision of basic case management
functions.

Division of Health Service Regulation

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

GIK Administrators caitially) ,
met withour then QP an
ots he. e deficiency
rin in his nes and
ositidn, iat Msg
retopil py ecu eha

8JRO14 MW continuation sheet 35 of 52

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERCLIA
IDENTIFICATION NUMBER:

MHL002-032
NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

TAYLORSVILLE, NC 28681

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

Continued From page 36

Review on 12/22/25 of Client #1's record
revealed:

Date of Admission 8/15/25.

-15 years old.

~Diagnoses of Oppositional Defiant Disorder
(ODD), Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorder and Anxiety
Disorder.

-No treatment plan.

Review on 12/22/25 of Client #2's record
revealed:

-Date of Admission 9/17/25.

-14 years old.

-Diagnoses of ODD and ADHD.

-No treatment plan.

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25,

-14 years old.

-Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.
-No treatment plan.

Review on 12/22/25 and 1/5/26 of facility records
revealed:

-No documentation that the QP provided
supervision to an Associate Professional (AP),
oversight of emergencies, psychoeducational
services, case management functions, or
participation and coordination of treatment plans.

Review on 1/6/26 of a Computer Aided Dispatch
(CAD) list dated 8/1/25-1/5/26 from the local
sheriffs department revealed:
-Law enforcement was called to Georgie's
Helping Hand Group Home for a "Missing
Person" on 11/6/25 and 12/3/25. When Client #3
eloped from the facility.

Division of Health Service Regulation

PRINTED: 01/22/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

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

‘W continuation sheet 37 of 52

PRINTED: 01/22/2026
FORM APPROVED

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

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

MHL002-032 B. WING. 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

‘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) CR TO THE APPROPRIATE

GEORGIE'S HELPING HAND

Continued From page 37

Interview on 1/5/26 with the Coordinator and
Behavior Specialist from the focal schoo! where
Clients #1, #2 and #3 attended revealed:

~"The facility does not share their (clients')
behaviors, violence tendency, triggers ..we have
learned about [Client #2's] sexual comments just
by him being here ...[Client #2] has made
statements of wanting to kill himself ...said he had
€ gun or a bomb ...I don't know if this was a
problem prior to him coming here ...[Client #3] ran
away from the facility 2 times. If a kid (client) runs
from the group home on Saturday, we need to
know that on Monday ...”

Interview on 1/6/26 with the QP revealed:
~-Unable to identify who was designated as the AP
for the facility.

-Regarding interventions and follow up to
incidents involving Client #3's elopements from
the facility on 11/6/25 and 12/23/25, "I wouldn't
Call it an incident, but it's part of [Client #3's]
diagnosis that he runs away at times, but it wasn't
‘on my shift so | can't speak so much about it
because | wasn't there and | don't speak on
things that I didn’t witness ...”

-Treatment plan "recommendations come from
where they (clients) were before and what their
interactions were, but that's not part of my forte. |
am limited on what | can speak. | don't do that.
That's not what I do ..."

-Coordination with educational services "That's
not my job. i stay in my lane ..."

Interview on 1/6/26 with the Executive
Director/Licensee revealed:
-The QP was "still learning” his responsibilities.

Interviews on 1/12/26 with the Director/Licensee

and the Executive Director/Licensee revealed:
Division of Health Service Regulation
STATE FORM 209 BURON M continuation sheet 38 of 52

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

V 295)

Division of Health Service Regulation

STATE FORM

MHL002-032

PRINTED: 01/22/2026
FORM APPROVED.

(X2) MULTIPLE CONSTRUCTION
A. BUILOING:

8. WING 01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 38
-The QP had been in his role for “about 2 years.”

This deficiency constitutes a re-cited deficiency.

This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.

27G .1703 Residential Tx. Child/Adol - Req. for A
P

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS

(a) {n addition to the qualified professional
specified in Rute .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of
an associate professional as set forth in 104
NCAC 27G .0104(1).

(b) The governing body responsible for each
facility shall develop and implement written
policies that specify the responsibilities of its
associate professional(s). At a minimum these
policies shall address the following:

q) management of the day to day
day-to-day operations of the facility;

(2) supervision of paraprofessionals
regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning
meetings.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the

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

a ug eer ing GHH

in is report

ele ted cae Fog

oe wu rato ors

poss vbly

uN" wo nally nN
er e ” Associ
iid CAF of re ony

fn. int Hrnal

ar ‘Crk

ft) jst tf Soe
designated
ne ts Signed i

ene deseripti JON form.
Shih i to enok losed f in
his sil e.

one 8JRO11 Ifcontinuation sheet 39 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA,

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
IDENTIFICATION NUMBER:

A. BUILDING: COMPLETED

MHL002-032 8. WING 01/12/2026

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

Division of Health Service Regulation

STATE FORM

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

Continued From page 35

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
Qualified Professional (QP) failed to perform
Clinical and administrative responsibilities at a
minimum to include the supervision of the
Associate Professional (AP), oversight of
emergencies, provision of direct
psychoeducational services, participation and
coordination of treatment plans, and provision of
case management functions. The findings are:

Review on 12/30/25 of the QP's record revealed:
-Date of Hire: 11/19/21.

-A job description signed by the QP on 9/29, but
lacked a legible year of signature: " ...Duties:
.-Develops, supervises and updates a client plan
of care to include type of services needed,
frequency of services needed, days services are
needed, and time of day services are needed
..Completes and records assessment, client's
plan of care for physician's, or other sources’
approval, including physicians orders plan for
treatment ...return upon completion all documents
to facility premises ...Completes supervision
standards, including Evaluations of all clients to
include at a minimum: Any and all changes to be
noted in clients current plan of care ...Document
any safety concems regarding client's current
condition related to mental, physical, emotional,
or living conditions. Document any suggestions in
resolving the concem ...Delegates tasks and
supervises Staff ..."

BJRO11

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

Ont till I MW, enter

di
dete Of ho

val tied, willang,
fs perros er

QP posi
Teal the job.

ches
accel ls ahs 7

If continuation sheet 36 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA
AN® PLAN OF CORRECTION

IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

MHL002-032 8. WING: 01/12/2026

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

Division of Health Service Regulation

STATE FORM

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

Continued From page 39

facility failed to employ a full-time Associate
Professional (AP) who ensured management of
the daily operations of the facility, supervision of
paraprofessionals, and participation in service
planning meetings. The findings are:

Review on 12/22/25 of the facility's Client and
Staff Census completed by the Program Director
on 12/22/25 revealed:

~An AP was not identified.

interview on 1/5/26 with the Program Director
revealed:

-He was not familiar with the term "AP" and
sought clarification.

-He could not confirm that an AP worked for the
facility.

interview on 1/6/26 with the Qualified
Professional revealed:

-He was unable to identify who was designated
as the AP for the facility.

interview on 12/23/25 with the Director/Licensee
revealed:
-An AP for the facility had not been hired yet.

Interview on 1/6/26 with the Executive
Director/Licensee revealed:
-The facility did not have an AP.

Interviews on 1/12/26 with the Director/Licensee
and the Executive Director/Licensee revealed:
-There had not been an AP for the facility since
August 2025.

This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.

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

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8JRO11 If continuation sheet 40 of 52

PRINTED: 01/22/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

MHL002.032 B. WING _______ 04/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28684

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

GEORGIE'S HELPING HAND

V 296 | Continued From page 40

27G .1704 Residential Tx. Child/Adol - Min. 7
40A NCAC 27G .1704 MINIMUM STAFFING Hot lost the
REQUIREMENTS Ps = . S
(a) A qualified professional shall be available by ti { foo i
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
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.

(a) 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.

Division of Health Service Regulation
STATE FORM Did 8JRO11 {foontinuation sheet 44 of 52

PRINTED: 01/22/2026
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

MHL002-032 B.WING 01/42/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE.
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

GEORGIE'S HELPING HAND

V 296} Continued From page 41

{e) Each facility shall be responsible for ensuring
supervision of children or adofescents 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
required minimum number of 2 direct care staff
for 1 to 4 clients were present. The findings are:

Review on 1/6/26 of the facility staff schedule On th e date of 12/22fap25,

sheets from 8/1/25 through 12/31/25 revealed: Si tH
-The Director/Licensee and the Executive SoS were “4 ely

{22208 ton 700.0 300 pm SS gob
i
of in. ony

Observation on 12/22/25 at 11:55 am revealed: Pid
-Clients' #1, #2 and #3 were in the living room oa
playing video games. K c
-The Program Manager was present and worked

alone with the 3 clients.

-At 12:58 pm Staff #1 arrived at the facility and

asked clients' if they wanted a snack.

Interviews on 12/22/25 and 1/5/26 with Client #1
revealed:
-There were "always 2 staff" present on all 3
shifts,
-"Today (12/22/25) was the first day (1 staff on
shift) ..."
Division of Health Service Regulation
STATE FORM 299 aJROMM M continuation sheet 42 of 52

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

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

MHL002-032 B. WING ___________ 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

Continued From page 42

Attempted interviews on 12/22/25, 12/30/25 and
1/5/26 with Clients #2 and #3 were unsuccessful
as both clients refused to be interviewed.

Interview on 12/22/25 with Staff #1 revealed:
-Worked the second shift, 3:00 pm - 11:00 pm.
~"l wasn't at the facility earlier (upon arrival)
because | ran to the store ...”

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

~The Executive Director/Licensee made the staff
schedule.

~"No set person (scheduled for a shift). | rotate
with everybody. I work all shifts. | am here pretty
much around the clock. | am in and out but here
every shift.”

~"We always schedule 2 staff to be present with
the boys (clients).”

Interview on 1/6/26 with the Qualified
Professionat revealed:

-Worked "mostly" the 3:00 pm - 11:00 pm shift
and the weekends; "There is no set time slots."
-"The house (facility) has to be covered by 2 staff
members, and [Executive Director/Licensee]
does the best that he can to make sure there is
always 2 people (staff) there ...If staff are not
available, then I've got to fill it, but there's no void
of staff at any given moment.”

Interviews on 1/6/26 and 1/12/26 with the
Executive Director/Licensee revealed:

-"l have a schedule sheet and it's indicated on my
schedule sheet ...| am here almost 24/7 and
make sure the staff are here ...and if staff don’t
come in, | have to fill in for them
~"l was at the store when you (Division of Health
Service Regulation surveyors) all came

Division of Health Service Regulation
STATE FORM 200 QJRON M continuation sheet 43 of 52

PRINTED: 01/22/2026

STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

MHL002-032 sehdiubie

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

FORM APPROVED

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

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

DEFICIENCY)
Continued From page 43
(12/22/25)."

This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.

27G .0603 Incident Response Requirements

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 I, 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;

©) 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

Division of Health Service Regulation
STATE FORM. e899

If continuation sheet 44 of 52

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

(X4)1D
PREFIX
TAG

Division of Health Service Regulation

STATE FORM

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

(2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 44

providers, excluding ICF/MR providers, shat!
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

immediately securing the client record

a) obtaining the client record;

(B) making a photocopy;

(Cc) certifying the copy's completeness; and
(D) transferring the copy to an intemal
Teview team;

(2) convening a meeting of an internal
review team within 24 hours of the incident. The
internat 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;

(8) 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

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

re a,
e Wey as or

a re -oceur Pence .

8JRON1 If continuation sheet 45 of 52

PRINTED: 01/22/2026
FORM APPROVED

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

MHL002.032 8. WING. 01/12/2026

NAME OF PROVIDER OR SUPPLIER. ‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

GEORGIE'S HELPING HAND

Continued From page 45

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 F por’ng

LME may give the provider an extension of up to f
three months to submit the final report; and iS ritend insti "
(3) immediately notifying the following: clud i” ou
(A) the LME responsible for the catchment as well) pou uv

area where the services are provided pursuant to Anal ia is indica tn
Rule .0604; Aisku Analy

(8) the LME where the client resides, if eck \ ver meas erin
different; Car I

(C) the provider agency with responsibility dil ized, PS

for maintaining and updating the client's aos
treatment plan, if different from the reporting wil 28 ae lay (4)

provider; prey’

(D) the Department; of theid

(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 policies regarding
documentation of Level {I incidents. The findings
are:

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.
Division of Health Service Regulation
STATE FORM ae 8JRO11 continuation sheet 46 of 62

PRINTED: 01/22/2026
FORM APPROVED

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

MHL002-032 B. WING, es 01/12/2026

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

(4) ID. ‘SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

GEORGIE'S HELPING HAND

Continued From page 47

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-The Director/Licensee was responsible to review
incidents and determine any actions needed.

-"| may glimpse them..."

Interview on 1/8/26 with the Director/Licensee
revealed:

-The staff who were on shift during an incident
were "responsible for filling out incident reports
and it comes to [Executive Director/Licensee].”
-She and the Executive Director/Licensee
determined what actions were needed when an
incident was received,

-She was unaware of notifications needed when
an incident occurred.

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

27G .0604 Incident Reporting Requirements

410A NCAC 27G .0604 = INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shail report all
{evel Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level II!
incidents and level I! 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

Division of Health Service Regulation
STATE FORM. bl 8JRO11

If continuation sheet 48 of 52

PRINTED: 01/22/2026
FORM APPROVED

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

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

MHL002-032 8. WING 01/42/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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)

GEORGIE'S HELPING HAND

V 367| Continued From page 48

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 incomptete 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
tequired on the incident form that was previously
unavailable.

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of alt level II!
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

Division of Health Service Regulation

STATE FORM ad BJRO11 {f continuation sheet 49 of $2

PRINTED: 01/22/2026
- FORM APPROVED
Division of Health Service
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(<2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL002-032 8. WING

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

490 RADIO ROAD
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

(X4)10
PREFIX
TAG

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

Continued From page 49

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 shalt 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 shail
include summary information as follows:

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

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

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

(6) the total number of level Il and level Ill
incidents that occurred; and

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level Il incidents in the
Incident Response Improvement System (IRIS),
failed to notify the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment area where
services were provided within 72 hours of

Division of Health Service Regulation
STATE FORM

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

DEFICIENCY)

lant ses
repos ¥ mienke
d asi Aa o/2625

did

spshice involverr
¢ ossisfance only
lve arrest,

forte, or any guiteome

ests the eriterto
ell II Treidents.

8JRO11 i continuation sheet 50 of 52

PRINTED: 01/22/2026
FORM APPROVED
Division of Health Service Regulation

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

MHL002-032 B. WING —________ 01/12/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

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

GEORGIE'S HELPING HAND

Continued From page 50
becoming aware of the incident. The findings are:

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Conduct Disorder and Disruptive Mood
Dysregulation Disorder.

Review on 12/22/25 and 1/5/26 of the IRIS from
10/1/25 - 1/5/26 revealed:
-No incidents were reported.

Review on 1/5/26 of facility incident reports from
10/1/25 - 1/5/26 revealed:

-11/6/25 at 6:00 p.m. and 12/3/25 at 6:40 p.m. -
Client #3 ran away from the facility and law
enforcement was called.

Attempted interviews on 12/22/25, 12/30/25 and
1/5/26 with Client #3 were unsuccessful as the
cllent refused to be interviewed.

Interview on 1/5/26 with the Program Director
revealed:

-Completed incident reports and “primarily it's
been with [Client #3]."

-After he completed the report he gave it to the
Executive Director/Licensee.

-The Executive Director/Licensee "reviews
internal incident reports and determines the levels
(of incidents)."

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-The Director/Licensee was responsible to review
incidents and determine any actions needed.

~"| may glimpse them...”

Division of Health Service Regulation
STATE FORM me 8JRO11 Ifcontinuation sheet 51 of 52

ti

PRINTED: 01/22/2026
FORM APPROVED.

STATEMENT OF DEFICIENCIES (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING:

MHL002-032 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
TAYLORSVILLE, NC 28681

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

GEORGIE’S HELPING HAND

7 | Continued From page 51

Interview on 1/8/26 with the Director/Licensee

revealed:

-The staff who were on shift during an incident

were "responsible for filling out incident reports eumentad oh

and it comes to [Executive Director/Licensee].” d ani $ 0
-She and the Executive Director/Licensee Y ni

determined if incidents should be entered into ° wt. ors’ a

IRIS.

~She was not aware contacts to law enforcement

needed to be entered into IRIS.

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

ment, ming «pasa, ,
é ilo inewden §
Al be | handled

qeeordia J repos ith
er, tad pout
manner, Wn!

have+
carted Si ua 5 of

Division of Heaith Service Regulation
STATE FORM e209 8JRO114 Hf continuation sheet 52 of 52