raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

PRINTED: 01/02/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

R
12/04/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

{W 000} | INITIAL COMMENTS

Arevisit was conducted on December 4, 2024 for
all previous deficiencies cited on October 2, 2024.
A total of 4 of the 10 deficiencies were not
corrected during the follow up survey.
Deficiencies will be re-cited.

{W 125} | PROTECTION OF CLIENTS RIGHTS

CFR(s): 483.420(a)(3)

The facility must ensure the rights of all clients.
Therefore, the facility must allow and encourage
individual clients to exercise their rights as clients
of the facility, and as citizens of the United States,
including the right to file complaints, and the right
to due process.

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure the right to dignity and respect
relative the use of adaptive equipment affecting 1
of 6 clients (#1). The finding is:

Afternoon observations on 10/1/24 at 5:15PM
revealed staff to assist client #1 with serving her
plate during the dinner meal. Continued
observations revealed staff to place client #1's
plate on top of her shirt protector on the dining
table.

Morning observations at 7:45AM on 10/2/24
revealed staff to again place client #1's plate on
top of her shirt protector on the dining table.

Interview with the home manager (HM) on
10/2/24 revealed that staff place the plate on top
of the shirt protector to minimize spillage.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 verified that staff

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

{W 000}

{W 125}

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: U56412

Facility ID: 924981 If continuation sheet Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 01/02/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
12/04/2024

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

PROVIDER'S PLAN OF CORRECTION (x5)

(x4) ID
PREFIX
TAG

COMPLETION
DATE

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

DEFICIENCY)

{W 125} | Continued From page 1

should not have placed client #1's plate on top of
her shirt protector. Continued interview with the
QIDP revealed that staff have been trained to use
place mats and dycem mats to minimize spillage
on the table and floor. Further interview with the
QIDP revealed that staff should protect the dignity
and respect of clients at all times.

Arevisit was completed on 12/4/24 to review the
supporting documentation according to the POC
provided. The supporting documentation did not
include all of the documentation as provided in
the POC submitted.

PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

{W 249}

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan.

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to ensure 6 of 6 clients (#1, #2,#3, #4, #5
and #6) received a continuous active treatment
program relative to formal and informal
interventions. The findings are:

A. The facility failed to ensure an active treatment
program for clients #1, #2, #3 and #4 resulting in
an extended amount of unstructured time. For
example:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56412

{W 125}

{W 249}

Facility ID: 924981

If continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 01/02/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
12/04/2024

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #1, #2, #3
and #4 to participate in the breakfast meal and sit
in the living room. Continued observations
revealed client #1, #2, #3, and #4 to remain
unengaged for approximately 50 minutes during
survey observations.

Review of record for client #1 on 10/2/24 revealed
a person centered plan (PCP) dated 4/11/24.
Continued review revealed the following training
objectives: participate in an activity of choice for
at least ten minutes, keep mouth closed during
meals, and signal staff when she needs to go to
the bathroom. Further review of the PCP revealed
informal training goals to include participation
more with activities, daily chores, monthly fire
drills, staying on task, meal preparation and
taking medication.

Review of record for client #2 on 10/2/24 revealed
a PCP dated 10/2/23. Continued review revealed
the following training objectives: exercise for 15
minutes, oral hygiene, select clothing, select an
activity of choice, math skills, and learn her
address.

Review of record for client #3 on 10/2/24 revealed
a PCP dated 6/12/24. Continued review revealed
the following training objectives: behavioral
interventions, toileting, bathing, use napkin while
eating, and exercise for ten minutes. Further
review of the PCP revealed informal training to
include participation in daily chores, fire drills, oral
hygiene, and safe habits while on the van.

Review of record for client #4 on 10/2/24 revealed
a PCP dated 9/13/24. Continued review revealed

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: U56412

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 249} | Continued From page 2 {W 249}

If continuation sheet Page 3 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 01/02/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
12/04/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

the following training objectives: behavioral
interventions, wash her hands, bathroom use,
swab her gums, choose activities, and exercise
while seated.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 confirmed clients
training objectives are current. Continued
interview with the QIDP revealed staff should
have prompted clients to engage in structured
activities.

B. The facility failed to ensure an active treatment
program for clients #5 and #6 during unstructured
time. For example:

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #5 and #6 to
participate in medication administration, the
breakfast meal, sit in the living room, and prepare
for showers. Continued observations revealed
clients #5 and #6 to remain unengaged for
approximately 50 minutes during survey
observations.

Review of record for client #5 on 10/2/24 revealed
a PCP dated 8/2/24. Continued review revealed
the following training objectives: brush teeth, use
the bathroom every two hours, exercise for 10
minutes, and prepare a beverage for a meal.

Review of record for client #6 on 10/2/24 revealed
a PCP dated 1/10/24. Continued review revealed
the following training objectives: wash hands,
brush teeth, go to bathroom every two hours,
place clothes in hamper, make a choice/select a
leisure activity, and exercise for 15 minutes.

Interview with the QIDP on 10/2/24 confirmed all

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: U56412

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 249} | Continued From page 3 {W 249}

Facility ID: 924981 If continuation sheet Page 4 of 6

PRINTED: 01/02/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346303 12/04/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

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

PROVIDER'S PLAN OF CORRECTION (x5)

(x4) ID
PREFIX
TAG

COMPLETION
DATE

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

DEFICIENCY)

{W 249} | Continued From page 4

clients training objectives are current. Continued
interview with the QIDP revealed clients should
have been offered opportunities to engage in
formal and informal training objectives to include
assisting staff with meal preparation and
completing chores.

Arevisit was completed on 12/4/24 to review the
supporting documentation relative to the POC
provided. There was no supporting
documentation provided according to the POC
submitted.

EVACUATION DRILLS

CFR(s): 483.470(i)(2)(iv)

{W 448}

The facility must investigate all problems with
evacuation drills, including accidents.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to investigate all problems relative to fire
evacuation drills including the justification for
extended times needed for facility evacuation.
The finding is:

Review of facility fire evacuation drill reports on
10/1/24 indicated fire drill reports were conducted
over the survey review year. Continued review of
the facility fire drills revealed multiple drills with
extended evacuation times to evacuate clients
from the facility. Further review of the fire drill
reports revealed multiple evacuations ranging
from 4 minutes to 5 minutes in length.
Subsequent review of fire drill reports indicated
the following drills were completed during first
shift with no identified problems noted: 9/2/24 (4
minutes), 3/8/24 (5 minutes), 2/3/24 (5 minutes),
1/31/24 (5 minutes), and 12/4/23 (5 minutes).

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56412

{W 249}

{W 448}

Facility ID: 924981

If continuation sheet Page 5 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 01/02/2025

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X3) DATE SURVEY

COMPLETED

R
12/04/2024

Additional review of facility documentation did not
reveal safety committee meeting notes relative to
follow up, justification, or reasoning for the
extended evacuation times. Continued review of
facility documentation did not identify specific
concerns or trends relative to the facility and
course of action to address corrective and
preventative actions. Review of facility
documentation also did not reveal whether
interventions specific to the facility were
completed addressing fire evacuation drill
concerns. Review of facility documentation did
not reveal in-service training relative to extended
fire evacuation drill concerns.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 revealed provider
fire drills over three minutes should be further
discussed in committee meetings. Continued
interview with the QIDP verified fire evacuation
drills specific to the facility were not presented
and discussed during safety committee meetings.
Further interview with the QIDP revealed he could
not verify if interventions and/or in-service training
had been completed relative to extended
evacuation times to ensure the safety of the
facility residents.

Arevisit was completed on 12/4/24 to review the
supporting documentation according to the POC
provided. Supporting documentation was not
provided according to the POC submitted.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56412

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 448} | Continued From page 5 {W 448}

Facility ID: 924981

If continuation sheet Page 6 of 6


state: NC

facility_name: Monroe Road

summary: Plan of Correction - MHLCS Follow-up

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

346303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(4) 1D
PREFIX
TAG

{W 000} | INITIAL COMMENTS

Arevisit was conducted on December 4, 2024 for
all previous deficiencies cited on October 2, 2024.
A total of 4 of the 10 deficiencies were not
Corrected during the follow up survey.

Deficiencies will be re-cited.

PROTECTION OF CLIENTS RIGHTS

CFR(s): 483.420(a)(3)

{W 125)

The facility must ensure the rights of all clients,
Therefore, the facility must allow and encourage
Individual clients to exercise their rights as clients
of the facility, and as citizens of the United States,
| including the right to file complaints, and the tight
to due process,

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure the right to dignity and respect
Tolative the use of adaptive equipment affecting 1
of 6 clients (#1). The finding is:

Afternoon observations on 10/1/24 at 5:15PM
Tevealed staff to assist client #1 with serving her
plate during the dinner meal. Continued
observations revealed staff to place client #1's
plate on top of her shirt protector on the dining
table,

Moming observations at 7:45AM on 10/2/24
revealed staff to again place client #1's plate on
top of her shirt protector on the dining table.

interview with the home manager (HM) on
10/2/24 revealed that staff place the plate on top
of the shirt protector to minimize spillage.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 verified that staff

-CTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

PRINTED: 01/02/2025

FORM APPROVED
OMB NO, 0938-039
(<2) MULTIPLE CONSTRUCTION }(X3) DATE SURVEY
A. BUILDING COMPLETED
R
B. WING ____________ 12/04/2024
STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONRCE ROAD
CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
{W000}
{W 125}

The QIDP will review client rights
with the client and guardian at
each Person Centered Plan Meet
ing and PCP updates. QIDP will
inservice Direct Support Supervior
and Direct Support Professionals
on Client Rights.

The IDD team will conduct meal
assessments 3 times per month
ensure the proper use of adaptive
equipment

(X6) OATE

([Y2sS

TITLE

A f : wWex—

Any deficiency statement énding with an asterisk (*) denotes a deficiency which the instifution may be excused from correcting providing it is determined fnat
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents ate made available to the facility. 1{ deficiencies are cited, an approved plan of correction is requisite to continued

program participation,

FORM CMS-2567(02-99} Previous Versions Obsoiste

Event ID; U56412

Factity ID: 924961 If continuation sheet Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES eR FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES. 1) PROVIDER/SUPPLIER/CLIA
ANO PLAN OF GORRECTION IDENTIFICATION NUMBER:

(2) MULTIPLE CONSTRUCTION

A. BUILDING a

346303 8. WING

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

7621 MONROE ROAD
CHARLOTTE, NC 28212

MONROE ROAD

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

DEFICIENCY)

{W 125} | Continued From page 4 {W 125}
should not have placed client #1's plate on top of
| her shirt protector. Continued interview with the

| QIDP revealed that staff have been trained to use
place mats and dycem mats to minimize spillage
on the table and floor. Further interview with the
QIDP revealed that staff should protect the dignity
and respect of clients at all times.

Arevisit was completed on 12/4/24 to review the
‘supporting documentation according to the POC
provided, The supporting documentation did not
include all of the documentation as provided in

the POC submitted.

{W 249} | PROGRAM IMPLEMENTATION {w249}} The IDT team will in-service staff
CFR(s): 483.440(a)(1) on how to effectively implement

active treatment to ensure client

As soon as the interdisciplinary team has #1, #2, #3, and client #4 do not
formulated a client's individual program plan, experience meaningful active
each client must receive a continuous active treatment for an extended amount
treatment program consisting of needed of time.

interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan,

The IDT team will conduct intera
ction engagement assessment,

unannounced and announced, 4
times a month.

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to ensure 6 of 6 clients (#1, #2,#3, #4, #5
and #6) received a continuous active treatment
program relative to formal and informal
interventions. The findings are:

A. The facility failed to ensure an active treatment
program for clients #1, #2, #3 and #4 resulting in
an extended amount of unstructured time. For
example;

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56412 Facility 1D: 924981 If continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES io

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO, 0938-039

STATEMENT OF DEFICIENCIES 41) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (43) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

R
12/04/2024

346303 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF GORRECTION os)
(GACH DEFICIENCY MUST BE PRECEDED BY FULL, (EACH CORRECTIVE ACTION SHOULD BE ‘COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE. are
DEFICIENCY)

MONROE ROAD

Continued From page 2

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #1, #2, #3
and #4 to participate in the breakfast meal and sit
in the living room. Continued observations
revealed client #1, #2, #3, and #4 to remain
unengaged for approximately 50 minutes during
survey observations,

Review of record for client #1 on 10/2/24 revealed
a person centered plan (PCP) dated 4/11/24.
Continued review revealed the following training
objectives: participate in an activity of choice for
at least ten minutes, keep mouth closed during
meals, and signal staff when she needs to go to
the bathroom. Further review of the PCP revealed
informal training goals to include participation
more with activities, daily chores, monthly fire
drills, staying on task, meal preparation and
taking medication.

Review of record for client #2 on 10/2/24 revealed
a PCP dated 10/2/23. Continued review revealed
the following training objectives: exercise for 15
minutes, oral hygiene, select clothing, select an
activity of choice, math skills, and learn her
address.

Review of record for client #3 on 10/2/24 revealed
a PCP dated 6/12/24. Continued review revealed
the following training objectives: behavioral
interventions, toileting, bathing, use napkin while
eating, and exercise for ten minutes. Further
review of the PCP revealed informal training to
include participation in daily chores, fire drills, oral
hygiene, and safe habits while on the van.

Review of record for client #4 on 10/2/24 revealed
a PCP dated 9/13/24. Continued review revealed

FORM CMS-2567(02-99) Previous Varsions Obsolete Event ID:U56412 Facilily ID; 824981 if continuation sheet Page 3 of 8

DEPARTMENT OF HEALTH AND HUMAN SERVICES rR RORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES. <1) PROVIDERSUPPLIERICLIA (2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘ABIDING: COMPLETED
R

12/04/2024

346303 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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)

MONROE ROAD

{W 249} | Continued From page 3 {W 249}
the following training objectives: behavioral
interventions, wash her hands, bathroom use,

swab her gums, choose activities, and exercise
while seated.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 confirmed clients
training objectives are current. Continued
interview with the QIDP revealed staff should
have prompted clients to engage in structured
activities.

B, The facility failed to ensure an active treatment
program for clients #5 and #6 during unstructured
time. For example:

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #5 and #6 to
participate in medication administration, the
breakfast meal, sit in the living room, and prepare
for showers. Continued observations revealed
clients #5 and #6 to remain unengaged for
approximately 50 minutes during survey
observations,

Review of record for client #5 on 10/2/24 revealed
a PCP dated 8/2/24. Continued review revealed
the following training objectives: brush teeth, use
the bathroom every two hours, exercise for 10
minutes, and prepare a beverage for a meal.

Review of record for client #6 on 10/2/24 revealed
a PCP dated 1/10/24, Continued review revealed
the following training objectives: wash hands,
brush teeth, go to bathroom every two hours,
Place clothes in hamper, make a choice/select a
leisure activity, and exercise for 15 minutes.

Interview with the QIDP on 10/2/24 confirmed all
re |

FORM CMS-2567(02-99) Previous Versions Obsolate Event !D: U56412 Facility ID; £24981 If continuation sheet Page 4 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES TE ORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICE

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF GORRECTION IDENTIFICATION NUMBER: A. BUILDING. COMPLETED

R
12/04/2024

34G303 8, WING
NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZiP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
SUMMARY STATEMENT OF DEFICIENCIES iD | PROVIDER'S PLAN OF CORRECTION

MONROE ROAD

(x4) 1D

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG GROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
+-——}-___— $$
{W 249} | Continued From page 4 {W 249}

1
clients training objectives are current. Continued |
interview with the QIDP revealed clients should |
have been offered opportunities to engage in |
formal and informal training objectives to include
assisting staff with meal preparation and
completing chores.

Arevisit was completed on 12/4/24 to review the
supporting documentation relative to the POC
provided. There was no supporting
documentation provided according to the POC
submitted.

{W448} | EVACUATION DRILLS {W 448}
CFR(s): 483.470()){2)(iv)

The IDT team will re-inservice
staff on fire procedures to ensure

investi i drills are conducted in less than
The facility must investigate all problems with a
evacuation dil, Inohuding accidents, 3 minutes, The QIDP and DSS
This STANDARD is nat met as evidenced by: will be present during some of th
Based on record review and interview, the facility fire drills, to ensure staff is follow
failed to investigate all problems relative to fire ing the fire drill evacuation proto
evacuation drills including the justification for col and to also, observe and do
extended times needed for facility evacuation. cument any problems the person|
The finding is: supported might encounter during

the fire drills.

Review of facility fire evacuation drill reports on

10/1/24 indicated fire drill reports were conducted The Safety Committee will meet
over the survey review year, Continued review of monthly Fire Drill Assessment

the facility fire drills revealed multiple drills with and make necessary changes to
extended evacuation times to evacuate clients ensure the safety evacuation that
from the facility. Further review of the fire drill are exxeeding 3 minutes.

reports revealed multiple evacuations ranging |

I a The Safety Committee will monitor

Subsequent review of fire drill reports indicated .
the following drills were completed during first the monthly Fire Drill Assessments

ast and make necessary changes to
shift with no identified problems noted: 9/2/24 (4 >
minutes), 3/8/24 (5 minutes), 2/3/24 (5 minutes), ensure the safety evacuation

1131/24 (5 minutes), and 12/4/23 (5 minutes) of pee Sr ebdeie the i

ff on any changes that will be im

FORM CMS-2567(02-89) Previous Versions Obsolete Event 1D:U58412 Facility ID: 924981 If continuation sheet Page 5 of 6

PRINTED: 01/02/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0394
STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: xoeone COMPLETED
R

346303 8. WING . 12/04/2024

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

7621 MONROE ROAD

CHARLOTTE, NC 28212

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF GORREGTION

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

MONROE ROAD

Continued From page 5 lemented to ensure a safe
Additional review of facility documentation did not evacuation of the clients.
reveal safety committee meeting notes relative to
follow up, justification, or reasoning for the
extended evacuation times. Continued review of
facility documentation did not identify specific
concems or trends relative to the facility and
course of action to address corrective and
preventative actions. Review of facility
documentation also did not reveal whether
interventions specific to the facility were
completed addressing fire evacuation drill
concerns. Review of facility documentation did
not reveal in-service training relative to extended
fire evacuation drill concerns,

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 revealed provider
fire drills over three minutes should be further
discussed in committee meetings. Continued
interview with the QIDP verified fire evacuation
drills specific to the facility were not presented
and discussed during safety committee meetings.
Further interview with the QIDP revealed he could
not verify if interventions and/or in-service training
had been completed relative to extended
evacuation times to ensure the safety of the
facility residents.

Arevisit was completed on 12/4/24 to review the
supporting documentation according to the POC
provided. Supporting documentation was not
provided according to the POC submitted.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:U56412 Facility 1D; 924961 IFcontinuation sheet Page 6 of 6

inspection_type: MHLCS Follow-up

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 10/09/2024
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 015] Subsistence Needs for Staff and Patients E015

CFR(s): 483.475(b)(1)

§403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)
(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1),
§483.475(b)(1), §485.542(b)(1), §485.625(b)(1)

[(b) Policies and procedures. [Facilities] must
develop and implement emergency preparedness
policies and procedures, based on the emergency
plan set forth in paragraph (a) of this section, risk
assessment at paragraph (a)(1) of this section,
and the communication plan at paragraph (c) of
this section. The policies and procedures must
be reviewed and updated every 2 years [annually
for LTC facilities]. At a minimum, the policies and
procedures must address the following:

(1) The provision of subsistence needs for staff
and patients whether they evacuate or shelter in
place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical
supplies

(ii) Alternate sources of energy to maintain the
following:

(A) Temperatures to protect patient health and
safety and for the safe and sanitary storage of
provisions.

(B) Emergency lighting.

(C) Fire detection, extinguishing, and alarm
systems.

(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6)(iii):]
Policies and procedures.

(6) The following are additional requirements for
hospice-operated inpatient care facilities only.
The policies and procedures must address the
following:

(iii) The provision of subsistence needs for

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411 Facility ID: 924981 If continuation sheet Page 1 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

hospice employees and patients, whether they
evacuate or shelter in place, include, but are not
limited to the following:

(A) Food, water, medical, and pharmaceutical
supplies.

(B) Alternate sources of energy to maintain the
following:

(1) Temperatures to protect patient health and
safety and for the safe and sanitary storage of
provisions.

(2) Emergency lighting.

(3) Fire detection, extinguishing, and alarm
systems.

(C) Sewage and waste disposal.

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility
failed to ensure the provision of subsistence
needs for clients and staff relative to the
emergency food supply. The finding is:

Observation of the facility's emergency food
supply on 10/1/24 revealed the emergency food
supply bin to contain various food items which
included cereal, 3 bottles of juice, multiple
packages of chocolate pudding, canned fruits,
vegetable goods, and paper products. Continued
observations revealed many of the food items
with expiration dates between 09/23-08/24.

Interview with the home manager (HM) on
10/1/24 revealed her intentions were to shop for
emergency supplies; however, there was an
emergency that required her immediate attention.
Continued interview with the HM revealed she
would discard all the expired food items.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 confirmed that
the facility should inspect the food regularly and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 015) Continued From page 1 E015

If continuation sheet Page 2 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

PRINTED: 10/09/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(X3) DATE SURVEY

COMPLETED

c
10/02/2024

(8)
COMPLETION
DATE

E015) Continued From page 2

ensure that the home has an adequate supply of
unexpired food.

W 000 | INITIAL COMMENTS

Arecertification and complaint investigation
survey was completed on 10/2/24 for intake
#NC00220216, #NC00222094, and
#NC00222271. The allegations were
unsubstantiated; however, deficiencies were cited
as a result of the recertification and complaint
investigation surveys.

PROTECTION OF CLIENTS RIGHTS

CFR(s): 483.420(a)(3)

W 125

The facility must ensure the rights of all clients.
Therefore, the facility must allow and encourage
individual clients to exercise their rights as clients
of the facility, and as citizens of the United States,
including the right to file complaints, and the right
to due process.

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure the right to dignity and respect
relative the use of adaptive equipment affecting 1
of 6 clients (#1). The finding is:

Afternoon observations on 10/1/24 at 5:15PM
revealed staff to assist client #1 with serving her
plate during the dinner meal. Continued
observations revealed staff to place client #1's
plate on top of her shirt protector on the dining
table.

Morning observations at 7:45AM on 10/2/24
revealed staff to again place client #1's plate on
top of her shirt protector on the dining table.

Interview with the home manager (HM) on

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

E015

W 000

W 125

Facility ID: 924981

If continuation sheet Page 3 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
10/02/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(8)
COMPLETION
DATE

W 125 | Continued From page 3

10/2/24 revealed that staff place the plate on top
of the shirt protector to minimize spillage.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 verified that staff
should not have placed client #1's plate on top of
her shirt protector. Continued interview with the
QIDP revealed that staff have been trained to use
place mats and dycem mats to minimize spillage
on the table and floor. Further interview with the
QIDP revealed that staff should protect the dignity
and respect of clients at all times.

STAFF TREATMENT OF CLIENTS

CFR(s): 483.420(d)(3)

W 154

The facility must have evidence that all alleged
violations are thoroughly investigated.

This STANDARD is not met as evidenced by:
Based on observations, documentation review
and interviews, the facility failed to show evidence
that allegations were thoroughly investigated
relative to two incidents of alleged verbal abuse of
1 of 6 clients (#2). The finding is:

Arecertification and complaint investigation
survey was completed on 10/2/24 relative to
allegations of client abuse and the nutritional
needs of clients. The allegations were
unsubstantiated.

Review of internal investigation summaries dated
6/26/24 and 9/15/24 revealed allegations of
abuse, exploitation, and bullying. Continued
review of the 6/26/24 internal investigation
revealed that a staff member pressured client #2
to purchase food items for them. Further review
of the internal investigation revealed a second
incident relative to client #2 and staff E engaging

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 125

W 154

Facility ID: 924981 If continuation sheet Page 4 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
10/02/2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

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

PROVIDER'S PLAN OF CORRECTION (x5)

(x4) ID
PREFIX
TAG

COMPLETION
DATE

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

DEFICIENCY)

W 154 | Continued From page 4

in a verbal altercation in the laundry room, which
led to the staff and client slamming the laundry
room door multiple times, along with screaming
and yelling from both parties. Review of the
6/2024 internal investigation also revealed
allegations that staff E cursed at client #2 and the
client went to her room crying and yelling.
Continued review of the 6/2024 internal
investigation did not reveal further investigation
relative to the laundry room incident between
client #2 and staff E.

Subsequent review of facility documentation
revealed an internal investigation dated 9/15/24
which indicated that staff E pushed client #2 in
the head and yelled in her face. Although the
allegation was unsubstantiated, additional
information was revealed relative to client #2
removing the helmet and gait belt from her
roommate. Continued review of the 9/2024
internal investigation revealed that staff E
addressed client #2 relative to removing the
roommate's adaptive equipment while
unsupervised in their room. Further review of the
9/2024 internal investigation did not reveal further
investigation relative to client #2 pulling off her
roommate's adaptive equipment while in their
room.

Interview with the program administrator on
10/2/24 revealed that additional information was
discovered during the internal investigations
however the additional information was not
further investigated. Continued interview with the
program administrator revealed that additional
information discovered during the primary
investigations should be investigated separately.

W 210 | INDIVIDUAL PROGRAM PLAN

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 154

W 210

Facility ID: 924981

If continuation sheet Page 5 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/09/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X3) DATE SURVEY

COMPLETED

c
10/02/2024

CFR(s): 483.440(c)(3)

Within 30 days after admission, the
interdisciplinary team must perform accurate
assessments or reassessments as needed to
supplement the preliminary evaluation conducted
prior to admission.

This STANDARD is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to ensure nutritional evaluations
were updated annually as prescribed. This
affected 5 of 6 clients (#1, #2, #3, #4 and #6).
The findings are:

A. Review of client #1's record on 10/2/24
revealed a nutritional evaluation (NA) dated
2/15/22.

B. Review of client #2's record on 10/2/24
revealed a NA dated 9/17/21.

C. Review of client #3's record on 10/2/24
revealed a NA dated 4/13/22.

D. Review of client #4's record on 10/2/24
revealed a NA dated 6/15/22.

E. Review of client 6#'s record on 10/2/24
revealed a NA dated 10/11/21.

Interview with the facility nurse on 10/2/24
revealed nutritional evaluations reviewed by
surveyors are the current ones on file. Continued
interview with the facility nurse revealed the
nutritional evaluations have not been updated.

Further interview with the qualified intellectual
disabilities professional (QIDP) and facility
administrator (FA) revealed the nutritional

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 210 | Continued From page 5 W 210

If continuation sheet Page 6 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

CFR(s): 483.440(c)(4)

The individual program plan states the specific
objectives necessary to meet the client's needs,
as identified by the comprehensive assessment
required by paragraph (c)(3) of this section.
This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to assure the
person-centered plan (PCP) included behavioral
interventions to support 1 of 3 sampled clients
(#2). The finding is:

Review of facility documentation during the
recertification and complaint survey from
10/1/24-10/2/24 revealed two internal
investigation summaries involving altercations
between client #2 and staff E and F on 6/26/24
and with staff E on 9/15/24. Continued review of
facility documentation revealed an internal
investigation summary dated 9/15/24 which
indicated that staff E reprimanded client #2 and
pushed her in the head and yelled in the client's
face. The allegation was unsubstantiated. The
internal investigation also revealed that client #2
also removed the gait belt and helmet of her
roommate on 9/16/24. Additional review of the
internal investigation revealed client #2 was
questioned about the allegations and provided
conflicting stories relative to the incidents. Review
of the internal investigation also revealed that

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 210 Continued From page 6 W 210
evaluations had not been updated due to the
facility not having a dietician on board since
8/2023. Additional interview with the QIDP and FA
revealed as of 7/2024 a dietician has been hired
however nutritional updates have not been
completed prior to the survey.
W 227 | INDIVIDUAL PROGRAM PLAN W 227

If continuation sheet Page 7 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

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

7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

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

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

(8)
COMPLETION
DATE

(x4) ID
PREFIX
TAG

DEFICIENCY)

W 227 | Continued From page 7

client #2 has a history of telling untruths.

Subsequent review of the facility documentation
revealed a PCP dated 10/2/23 and a behavior
support plan (BSP) for client #2 dated 10/1/24
revealed the following target behaviors:
overeating, skin picking, and
noncompliance-refusal. Review of the record for
client #2 did not reveal behavioral interventions
relative to telling untruths.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 revealed that
client #2 has a history of corroborating stories.
Continued interview with the QIDP and program
administrator revealed that client #2 has a history
of telling untruths towards staff and peers.
Interview with the QIDP and program
administrator also revealed that client #2 cries,
yells, and screams when she is being confronted
regarding her behaviors. Further interview with
the QIDP and program administrator revealed
that client #2 should have behavioral
interventions relative to addressing telling
untruths.

PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

W 249

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 227

W 249

Facility ID: 924981

If continuation sheet Page 8 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
10/02/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to ensure 6 of 6 clients (#1, #2,#3, #4, #5
and #6) received a continuous active treatment
program relative to formal and informal
interventions. The findings are:

A. The facility failed to ensure an active treatment
program for clients #1, #2, #3 and #4 resulting in
an extended amount of unstructured time. For
example:

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #1, #2, #3
and #4 to participate in the breakfast meal and sit
in the living room. Continued observations
revealed client #1, #2, #3, and #4 to remain
unengaged for approximately 50 minutes during
survey observations.

Review of record for client #1 on 10/2/24 revealed
a person centered plan (PCP) dated 4/11/24.
Continued review revealed the following training
objectives: participate in an activity of choice for
at least ten minutes, keep mouth closed during
meals, and signal staff when she needs to go to
the bathroom. Further review of the PCP revealed
informal training goals to include participation
more with activities, daily chores, monthly fire
drills, staying on task, meal preparation and
taking medication.

Review of record for client #2 on 10/2/24 revealed
a PCP dated 10/2/23. Continued review revealed
the following training objectives: exercise for 15
minutes, oral hygiene, select clothing, select an
activity of choice, math skills, and learn her
address.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 | Continued From page 8 W 249

Facility ID: 924981 If continuation sheet Page 9 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

Review of record for client #3 on 10/2/24 revealed
a PCP dated 6/12/24. Continued review revealed
the following training objectives: behavioral
interventions, toileting, bathing, use napkin while
eating, and exercise for ten minutes. Further
review of the PCP revealed informal training to
include participation in daily chores, fire drills, oral
hygiene, and safe habits while on the van.

Review of record for client #4 on 10/2/24 revealed
a PCP dated 9/13/24. Continued review revealed
the following training objectives: behavioral
interventions, wash her hands, bathroom use,
swab her gums, choose activities, and exercise
while seated.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 confirmed clients
training objectives are current. Continued
interview with the QIDP revealed staff should
have prompted clients to engage in structured
activities.

B. The facility failed to ensure an active treatment
program for clients #5 and #6 during unstructured
time. For example:

Observations in the group home on 10/2/24 from
6:30 AM to 8:00 AM revealed clients #5 and #6 to
participate in medication administration, the
breakfast meal, sit in the living room, and prepare
for showers. Continued observations revealed
clients #5 and #6 to remain unengaged for
approximately 50 minutes during survey
observations.

Review of record for client #5 on 10/2/24 revealed
a PCP dated 8/2/24. Continued review revealed

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: U56411

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 | Continued From page 9 W 249

If continuation sheet Page 10 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

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

7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

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

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

(8)
COMPLETION
DATE

(x4) ID
PREFIX
TAG

DEFICIENCY)

W 249 | Continued From page 10

the following training objectives: brush teeth, use
the bathroom every two hours, exercise for 10
minutes, and prepare a beverage for a meal.

Review of record for client #6 on 10/2/24 revealed
a PCP dated 1/10/24. Continued review revealed
the following training objectives: wash hands,
brush teeth, go to bathroom every two hours,
place clothes in hamper, make a choice/select a
leisure activity, and exercise for 15 minutes.

Interview with the QIDP on 10/2/24 confirmed all
clients training objectives are current. Continued
interview with the QIDP revealed clients should
have been offered opportunities to engage in
formal and informal training objectives to include
assisting staff with meal preparation and
completing chores.

EVACUATION DRILLS

CFR(s): 483.470(i)(2)(iv)

W 448

The facility must investigate all problems with
evacuation drills, including accidents.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to investigate all problems relative to fire
evacuation drills including the justification for
extended times needed for facility evacuation.
The finding is:

Review of facility fire evacuation drill reports on
10/1/24 indicated fire drill reports were conducted
over the survey review year. Continued review of
the facility fire drills revealed multiple drills with
extended evacuation times to evacuate clients
from the facility. Further review of the fire drill
reports revealed multiple evacuations ranging
from 4 minutes to 5 minutes in length.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 249

W 448

Facility ID: 924981

If continuation sheet Page 11 of 17

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
10/02/2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

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

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

(8)
COMPLETION
DATE

(x4) ID
PREFIX
TAG

DEFICIENCY)

W 448 | Continued From page 11

Subsequent review of fire drill reports indicated
the following drills were completed during first
shift with no identified problems noted: 9/2/24 (4
minutes), 3/8/24 (5 minutes), 2/3/24 (5 minutes),
1/31/24 (5 minutes), and 12/4/23 (5 minutes).

Additional review of facility documentation did not
reveal safety committee meeting notes relative to
follow up, justification, or reasoning for the
extended evacuation times. Continued review of
facility documentation did not identify specific
concerns or trends relative to the facility and
course of action to address corrective and
preventative actions. Review of facility
documentation also did not reveal whether
interventions specific to the facility were
completed addressing fire evacuation drill
concerns. Review of facility documentation did
not reveal in-service training relative to extended
fire evacuation drill concerns.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 revealed provider
fire drills over three minutes should be further
discussed in committee meetings. Continued
interview with the QIDP verified fire evacuation
drills specific to the facility were not presented
and discussed during safety committee meetings.
Further interview with the QIDP revealed he could
not verify if interventions and/or in-service training
had been completed relative to extended
evacuation times to ensure the safety of the
facility residents.

FOOD AND NUTRITION SERVICES

CFR(s): 483.480(a)(4)

W 463

The client's interdisciplinary team, including a
qualified dietitian and physician must prescribe all

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 448

W 463

Facility ID: 924981

If continuation sheet Page 12 of 17,

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

modified and special diets.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure food was
served according to their specially prescribed
diets for 2 of 6 clients (#4, #5). The findings are:

Afternoon observations on 10/1/24 at 5:20PM
revealed client #4 to sit at the dining room table to
prepare for the dinner meal. The dinner meal
consisted of baked chicken, green beans, rice,
gravy, pudding, 2% milk, and sugar free
beverage. Continued observations revealed client
#4 to eat her meal in its entirety. Further
observations revealed staff to provide client #4
with seconds of chicken, rice and gravy. At no
point during the observation did staff provide
client #4 with seconds of vegetables as
prescribed.

Subsequent observations during the dinner meal
revealed client #5 to sit at the dining table and
participate in the dinner meal. Continued
observations revealed staff to provide client #5
with seconds of rice and gravy. Further
observations revealed client#5 to consumer her
meal and seconds in its entirety. At no point
during the observation did staff provide client #5
with a double portion of vegetables.

Review of the record for client #4 on 10/2/24
revealed a person centered plan (PCP) dated
9/13/24 which indicated the client has the
following diet: 4" chopped, low fat, low
cholesterol, heart healthy, seconds of vegetable
only, and soften dry cereal with milk.

Review of the record for client #5 revealed a PCP
dated 8/2/24 which indicated the client has the

Event ID: U56411

FORM CMS-2567(02-99) Previous Versions Obsolete

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 463 | Continued From page 12 W 463

If continuation sheet Page 13 of 17,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
10/02/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(8)
COMPLETION
DATE

W 463 | Continued From page 13

following prescribed diet: 1500 calorie,
mechanical soft diet with 4" consistency, 100
calorie snacks or less, and double portion
vegetables.

Interview with nursing services on 10/2/24
revealed that client #4 and #5's diet orders are
current. Continued interview with nursing services
verified that client #5's diet changed after her
recent hospitalization due to a diagnosis of
cirrhosis with esophageal varices, GI bleeding,
and status post banding.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 revealed that staff
have been trained to follow clients' prescribed
diets. Continued interview with the QIDP verified
that client #4 and #5's diet orders are current.
Further interview with the QIDP revealed that staff
should follow client's diet orders as prescribed.
MEAL SERVICES

CFR(s): 483.480(b)(2)(ii)

W 473

Food must be served at appropriate temperature.
This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure all foods were served at an
appropriate temperature for 6 of 6 clients (#1, #2,
#3, #4, #5 and #6). The finding is:

Observations upon entering the group home on
10/1/24 at 4:15 PM revealed a dinner meal to
include baked chicken in the oven, string green
beans, and gravy sitting uncovered on the kitchen
stove. Continued observations at 5:10 PM - 5:13
PM revealed clients #1, #2, #3, #4, #5 and #6 to
sit at the dinner table and begin their dinner meal.
Further observations revealed no effort from staff

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 463

W 473

Facility ID: 924981 If continuation sheet Page 14 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

PRINTED: 10/09/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(X3) DATE SURVEY

COMPLETED

c
10/02/2024

(8)
COMPLETION
DATE

DEFICIENCY)

W 473 | Continued From page 14

to reheat the dinner menu items, which indicated
a range of 45 to 58 minutes the dinner items sat
uncovered on the kitchen counter and oven
before being served.

Interview with the qualified intellectual disabilities
professional (QIDP) on 10/2/24 confirmed the
dinner meal should have been covered and
reheated prior to being served.

MEAL SERVICES

CFR(s): 483.480(b)(2)(iii)

W 474

Food must be served in a form consistent with the
developmental level of the client.

This STANDARD is not met as evidenced by:
Based on observations, record review, and
interview the facility failed to ensure food for 3
clients (#1, #4 and #5) were served in a form
consistent with their developmental level. The
findings are:

Observations in the group home on 10/1/24 at
4:15 PM revealed the dinner meal to be baked
chicken, rice, gravy, green string beans, jello
pudding, juice and milk. Continued observations
between 5:10 PM - 5:13 PM revealed all clients to
sit at the table and consume their dinner meal.
Further observations revealed client #1 to eat
chicken pieces not cut into 1/2" chopped pieces
and at one point placed a big piece of chicken in
her mouth then later spit it out. Subsequent
observations revealed client #4 to consume
chicken pieces not cut into 1/4" pieces. Additional
observations revealed client #5 to consume
chicken pieces, rice and string green beans in it's
original state. At no point during observations did
staff offer clients #1, #4 and #5 their dinner meal
in the form consistent to their prescribed diets.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

W 473

W 474

Facility ID: 924981

If continuation sheet Page 15 of 17,

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 10/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

Observations in the group home on 10/2/24 at
6:50 AM revealed the breakfast meal to consist of
waffles, grits, juice, and milk. Continued
observations between 6:50 AM - 6:59 AM
revealed all clients to sit at the table and
consume their breakfast meal. Further
observations revealed client #1 to eat whole
waffles not cut into 1/2" chopped pieces.
Subsequent observations revealed client #4 to
consume whole waffles not cut into 1/4" pieces.
Additional observations revealed client #5 to
consume whole waffles in it's original state. At no
point during observations did staff offer clients #1,
#4 and #5 their dinner meal in the form consistent
to their prescribed diets.

Review of client #1's record on 10/2/24 revealed
a nutritional evaluation (NA) dated 2/15/22.
Review of the NA indicated client #1's diet order
is 1 inch chopped, weight loss, 1800 calories.

Review of client #4's record on 10/2/24 revealed
a NA dated 6/15/22. Review of the NA indicated
client #4's diet order is 4" consistency, weight
loss (1800 calorie), with seconds of vegetables
only.

Review of client #5's record on 10/2/24 revealed
a NA dated 5/11/24. Review of the NA indicated
client #5's diet order is 1500 calorie, mechanical
soft, 1/4" inch consistency.

Interview with nursing services (RN) on 10/2/24
revealed there have been significant changes
with client #5's diet order due to a hospitalization
from 5/6/24-5/11/24 which resulted in GI bleeding,

Interview with the facility qualified intellectual

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 474 | Continued From page 15 W 474

If continuation sheet Page 16 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

SUMMARY STATEMENT OF DEFICIENCIES

PRINTED: 10/09/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PROVIDER'S PLAN OF CORRECTION

COMPLETED

c
10/02/2024

disabilities professional (QIDP) confirmed client
#1, #4 and #5's diet orders are current. Continued
interview with the QIDP confirmed client #1, #4
and #5's food was not prepared to the
specifications of their diet orders. Further
interview with the QIDP confirmed the diet orders
for the clients should be followed as prescribed at
all times.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U56411

(x4) ID ID (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 474 | Continued From page 16 W 474

Facility ID: 924981

If continuation sheet Page 17 of 17

inspection_type: MHLCS Annual

document_type: Statement of Deficiency