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

raw_content:
PRINTED: 01/14/2026
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

R
MHL013-212 B. WING _____ 12/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
CONCORD, NC 28025

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

DEFICIENCY)

ADRIENNE'S HOUSE

V 000} INITIAL COMMENTS Vv 000

An annual, complaint and follow-up survey was
completed on 12/19/2025. One complaint was
substantiated (Intake #NC00234405) and one
complaint was unsubstantiated (Intake
#NC00234407). Deficiencies were cited.

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

This facility is licensed for 4 and currently has a
census of 2. The survey sample consisted of
audits of 2 current clients and 4 former clients.

V 114) 27G .0207 Emergency Plans and Supplies Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Each facility shall develop a written fire plan
and a disaster plan and shall make a copy of
these plans available

to the county emergency services agencies upon
request. The plans shall include evacuation
procedures and routes.

(b) The plans shall be made available to all staff
and evacuation procedures and routes shall be
posted in the

facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift.

Drills shall be conducted under conditions that
simulate the facility's response to fire
emergencies.

(d) Each facility shall have a first aid kit
accessible for use.

This Rule is not met as evidenced by:

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 1QK511 If continuation sheet 1 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 1 Vv 114

Based on record reviews and interviews, the
facility failed to ensure fire and disaster drills were
conducted quarterly and repeated on each shift.
The findings are:

Review on 12/04/2025 of the facility's fire and
disaster drills log from 01/01/2025 - 11/25/2025
revealed:

-There were no second shift (8 pm-8 am) fire and
disaster drills for the first quarter from
01/01/2025-03/31/2025.

-There were no first shift (8 am-8 pm) or second
shift (8 pm-8 am) fire and disaster drills for the
second quarter from 04/01/2025-06/30/2025.

Interview on 12/04/2025 with Client #1 revealed:
-He lived at the facility since last December 2024.
-"We do them (fire and disaster drills), but we
have not done them in a month or two. We have
not done them in awhile."

Interview on 12/04/2025 with Client #2 revealed:
-He lived at the facility for approximately one
month.

-"| have had them (fire and disaster drills) 2 times
since | have been here."

Interview on 12/08/2025 with Staff #2 revealed:
-"Yes ma'am, [Executive Director] do them (fire
and disaster drills). She is responsible for doing
the drills on each shift."

Interview on 12/16/2025 with the Former
Associate Professional revealed:

-"| don't remember doing them (fire and disaster
drills)."

Interviews on 12/04/2025 and 12/19/2025 with the
Qualified Professional/Licensee revealed:

-First shift was 8 am-8 pm and second shift was 8
Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 2 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114| Continued From page 2 Vv 114
pm-8 am.
-"Moving forward, we are going to do fire and
disaster drills monthly on each shift. We have
updated our form to account for that (ensuring
that drills were completed each month and on
each shift)."
V 118] 27G .0209 (C) Medication Requirements V 118

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(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 shal
clients only when au
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.

be self-administered by
horized in writing by the

Division of Health Service Regulation

STATE FORM 6899

1QK511

If continuation sheet 3 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

This Rule is not met as evidenced by:

Based on observations, record reviews, and
interviews, the facility failed to ensure
medications were administered on the written
order of a physician affecting 2 of 2 Current
Clients (#1 and #2) and 4 of 4 Former Clients (FC
#3, #4, #5, and #6), failed to keep the MAR
current affecting 2 of 2 Current Clients (#1 and
#2) and 4 of 4 FCs (#3, #4, #5, and #6), and
failed to ensure medications were available
affecting 1 of 2 Current Clients (#1) and 3 of 4
FCs (#3, #5, and #6). The findings are:

CROSS REFERENCE: 10A NCAC 27G .0209
Medication Requirements (V120). Based on
record reviews, observations and interviews, the
facility failed to ensure medications were stored
separately affecting 1 of 2 Current Clients (#1).

CROSS REFERENCE: 10A NCAC 27G .0209
Medication Requirements (V121). Based on
records reviews and interviews, the facility failed
to obtain drug regimen reviews every six months
for 1 of 2 Current Clients (#1) who received
psychotropic drugs.

CROSS REFERENCE: 10A NCAC 27G .0209
Medication Requirements (V123). Based on
record reviews and interviews, the facility failed to
ensure all medication administration errors were
immediately reported to a pharmacist or physician
affecting 2 of 2 Current Clients (#1 and #2) and 4
of 4 FCs (#3, #4, #5, and #6).

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 118| Continued From page 3 V 118

If continuation sheet 4 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Finding #1:

Review on 12/04/2025 of Client #1's record
revealed:
There were no physician orders for the following
over-the-counter medications:
-Milk of Magnesium (Constipation).
-MiraLAX (Constipation).
-Allergey Relief (Allergies).
-lbuprofen (Pain or Fever Reducer).
-Pain Reliever (Pain Relief).
There were no discontinue orders for:
-Fluoxetine HCL 20 mg (Antidepressant).
-Azstarys 52.3-10.4 mg (ADHD).

Reviews on 12/04/2025 and 12/16/2025 of Client
#1's MARs from 06/01/2025 - 11/30/2025
revealed:
Client #1 was administered the following
medications.
A.
There were no transcriptions for quantity:

-Omeprazole 20 mg.

-Aripiprazole 5 mg.

-Fluoxetine HCL 20 mg.

-Clonidine .2 mg.

-Atomoxetine 100 mg.

-Melatonin 10 mg.

-Trazodone 100 mg.
There was no transcription instructions for:

-Hydrocortisone 2.5% Ointment.
There was no transcription instructions,
frequency, or quantity:

-Hydroxyzine 50 mg from
09/01/2025-09/30/2025.

-Dyanavel ER 5 mg from
11/01/2025-11/30/2025.

-Cetirizine 10 mg from
06/01/2025-09/30/2025.
Division of Health Service Regulation
STATE FORM

6899 1QK511

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

DEFICIENCY)
V 118| Continued From page 4 V 118

If continuation sheet 5 of 48

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 5 V 118

Client #1 had a total of 66 MAR transcription
omissions.

There was a handwritten note that Azstarys
52.3-10.4 mg was discontinued on 09/10/2025.
There was a handwritten note that Fluoxetine
HCL 20 mg was discontinued on 09/17/2025.
Client #1 had a total of 12 medication doses with
no staff initials for administration.

Client #1 had a total of 142 medication doses not
administered and documented with an "X" or
circle around staff initials.

Client #1 had a total of 16 medication doses
unavailable at the facility for administration.

Reviews on 12/04/2025 and 12/16/2025 of Client
#1's MAR Comment Section from 06/01/2025 -
11/30/2025 revealed:

The following over-the-counter medications were
administered:

-Milk of Magnesium on 06/03/2025 and
06/09/2025.

-MiraLAX on 10/01/2025.

-Allergey Relief on 09/24/2025 and 09/28/2025.
-lbuprofen on 09/28/2025 and 09/29/2025.

-Pain Reliever on 10/28/2025 and 10/29/2025.

Observation on 12/04/2025 at 3:12 pm of Client
#1's medication container revealed:

-Aripiprazole 5 mg, Fluoxetine HCL, Clonidine .2
mg, Atomoxetine 100 mg, Melatonin 10 mg,
Hydroxyzine 50 mg, Trazodone 100 mg,
Omeprazole 20 mg, Dyanavel ER 5 mg, Cetirizine
10 mg, Albuterol HFA 90 MCG, Hydrocortisone
2.5% Ointment, Ventolin HFA and Polyethylene
Glycol were present.

Finding #2:

Reviews on 12/05/2025 and 12/12/2025 of Client
#2's record revealed:

Division of Health Service Regulation
STATE FORM 6899

1QK511

If continuation sheet 6 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

There was a physician order dated 09/16/2025:

-Abilify 5 mg (Antipsychotic)- Take 1 tab by
mouth in the morning.
There were no physician orders for:

-Depakote ER 500 mg (Mood Stabilizer)- Take 2
tabs by mouth.

-Trazodone 50 mg (Sleep Aid)- Take 1 tab by
mouth.
There were no physician orders for the following
over-the-counter medications:

-lbuprofen (Pain or Fever Reducer).

-Pepto Bismol (Stomach Ache).

-Tussin DM (Dextromethorphan) (Cough
Suppressant).

Reviews on 12/05/2025 and 12/12/2025 of Client
2's MARS from 11/01/2025 - 11/30/2025
revealed:

-Staff documented Client #1 was administered
Depakote ER 500 mg on 11/01/2025-11/03/2025,
11/05/2025, 11/06/2025, 11/08/2025-11/10/2025,
11/15/2025-11/19/2025 and Trazodone 50 mg on
11/01/2025 - 11/13/2025, 11/15/2025-11/18/2025,
and 11/21/2025-11/27/2025.

-Staff documented an X and/or circle around staff
initials to total 15 unadministered medication
doses for Client #2.

Reviews on 12/05/2025 and 12/12/2025 of Client
#2's MAR Comment Sections from 10/29/2025 -
11/30/2025 revealed:

The following over-the-counter medications were
administered:

-lbuprofen on 11/01/2025 and 11/16/2025.
-Pepto Bismol on 11/11/2025 and 11/29/2025.
-Tussin DM on 11/16/2025.

Observation on 12/05/2025 at 2:41 pm of Client
#2's medication container revealed:

-Abilify 5 mg, Depakote ER 500 mg and

Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 6 V 118

If continuation sheet 7 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

ID
PREFIX
TAG

(X4) ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 7 V 118

Trazodone 50 mg were present.
-There were no over-the-counter medications
present.

Finding #3:

Reviews on 12/08/2025 and 12/12/2025 of FC
#3's record revealed:

There were no physician orders for the following
over-the-counter medications:

-lbuprofen (Pain or Fever Reducer).

-MiraLAX (Constipation).

-Tylenol (Pain Relief).

-Clear lax (Constipation).

Reviews on 12/08/2025 and 12/12/2025 of FC
#3's MARs from 08/01/2025 - 11/30/2025
revealed:

-Magnesium 100 mg- gummies were transcribed
instead of tabs and was administered to FC #3
rom 08/01/2025-08/30/2025.

-Children's Multivitamin-Immune- gummies were
ranscribed instead of tabs and was administered
io FC #3 from 08/01/2025-10/31/2025.

FC #3 had a total of 1 medication dose with no
staff initial for administration.

FC#3 had a total of 37 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

FC #3 had a total of 4 medication doses
unavailable at the facility for administration.

Reviews on 12/08/2025 and 12/12/2025 of FC
#3's MAR Comment Sections from 08/01/2025 -
11/30/2025 revealed:

The following over-the-counter medications were
administered:

-lbuprofen on 08/07/2025, 08/07/2025.
-MiraLAX on 08/23/2025, 09/12/2025 and
09/18/2025.

Division of Health Service Regulation

STATE FORM

6899 1QK511

If continuation sheet 8 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

-Tylenol on 09/09/2025, 09/11/2025, 09/30/2025
and 10/25/2025.
-Clear lax on 10/01/2025 and 10/02/2025.

Finding #4:

Review on 12/09/2025 of FC #4's record
revealed:

There were no physician order for the following
over-the-counter medications:

-lbuprofen (Pain Relief or Fever Reducer).

Reviews on 12/08/2025 and 12/12/2025 of FC
#4's MARS from 08/01/2025 - 08/30/2025
revealed:
A.
There was no quantity for:

-Amantadine HCL 100 mg.

-Benztropine 1 mg.

-Bupropion HCL SR 150 mg.

-Clonidine HCL .2 mg.

-Desmopressin .2 mg.

-Desvenlasfaxine Succinate ER 100 mg.

-Lamotrigine ER 200 mg.

-Lurasidone 60 mg.

-Oxybutynin Chloride 5 mg.

-Cephalexin 500 mg.
-lbuprofen was transcribed on the MAR.
Staff documented FC #4 was administered the
above medications between 08/01/2025 and
08/30/2025.
FC #4 had a total of 10 MAR transcription issues.
FC #4 had a total of 275 medication doses with
no staff initials for administration.
FC #4 had a total of 7 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

Finding #5:

Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 118| Continued From page 8 V 118

If continuation sheet 9 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Review on 12/09/2025 of FC #5's record
revealed:
There were no physician order sfor the following
over-the-counter medications:

-Cold and Flu medication (Cold or Flu).

-Pain Reliever 500 mg (Pain).

Review on 12/09/2025 of FC #5's MARS from
08/01/2025 - 10/31/2025 revealed:
A.
There was no quantity for:

-Clonidine .1 mg.

-Atomoxetine 25 mg.

-Risperidone 2 mg.

-Oxcarbazepine 600 mg.

-Melatonin 3 mg.
There was no instructions for:

-Clonidine .1 mg from 08/01/2025-08/30/2025
There was no transcription for:

-Melatonin 3 mg from 08/27/2025-
08/30/2025.
Staff documented FC #5 was administered the
above medications between 08/01/2025 and
10/31/2025.
FC #5 had a total o
omissions.
FC #5 had a total of 12 medication doses with no
staff initials for administration.
FC #5 had a total of 38 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.
FC #5 had a total of 17 medication doses
unavailable at the facility for administration.

15 MAR transcription

Review on 12/09/2025 of FC #5's MAR Comment

Sections from 08/01/2025 - 10/31/2025 revealed:

The following over-the-counter medications were

administered:
-Cold and Flu medication on 10/24/2025.
-Pain Reliever on 10/08/2025.

Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 9 V 118

If continuation sheet 10 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Finding #6:

Review on 12/15/2025 of FC #6's record
revealed:
There were no physician orders for:
-Cephalexin 500 mg (Antibiotic)- Take 1 cap by
mouth twice a day for 7 days.
-Clindamycin 300 mg (Antibiotic).
-Chlorhexidine .12% (Antiseptic).
-Dexamethasone 2 mg (Steroid).
There were no physician orders for the following
over-the-counter medications:
-Cold and Flu medication (Cold or Flu).
-Cough drops (Sore throat).
-Vapor Rub (Congestion).
-Acetaminophen (Pain or Fever Reducer).
-lbuprofen 400 mg (Pain or Fever Reducer).
-Aleve (Pain or Fever Reducer).
-Pepto Bismol (Stomach Ache).

Review on 12/17/2025 of FC #6's MARS from
03/01/2025 - 08/30/2025 revealed:
A.
There was no quantity:

-Hydroxyzine HCL 50 mg.

-Melatonin 5 mg.

-Propranolol HCL 20 mg.

-Sertraline HCL 100 mg.

-Cetirizine HCL 10 mg.
FC #6 had a total of 30 MAR transcription
omissions.
FC #6 had a total of 10 medication doses with no
staff initials for administration.
FC #6 had a total of 97 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.
FC #6 had a total of 3 medication doses
unavailable at the facility for administration.

Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 118| Continued From page 10 V 118

If continuation sheet 11 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Review on 12/17/2025 of FC #6's MAR Comment
Section from 03/01/2025 - 08/30/2025 revealed:
The following medications were documented as
administered:

-Cephalexin 500 mg on 04/25/2025-04/30/2025..
-Clindamycin 300 mg on 05/01/2025-05/03/2025.
-Chlorhexidine .12% on 05/01/2025-05/10/2025.
-Dexamethasone 2 mg on
05/01/2025-05/03/2025.

The following over-the-counter medications were
documented as administered:

-Cold and Flu medication on 05/13/2025.
-Cough drops on 04/22/2025 and 07/17/2025.
-Vapor Rub on 04/21/2025, 04/28/2025.
-Acetaminophen on 05/01/2025, 05/02/2025,
05/04/2025

-lbuprofen 400 mg on 05/01/2025, 05/02/2025,
05/05/2025-05/09/2025, 05/12/2025-05/14/2025,
06/03/2025, 06/05/2025, 06/09/2025, 06/12/2025,
07/09/2025, 07/20/2025 and 08/25/2025.

-Pepto Bismol on 05/13/2025 and 06/14/2025.
-Aleve on 03/10/2025, 04/04/2025, 04/17/2025
and 04/19/2025.

Interview on 12/08/25 with the Executive Director
(ED) revealed:

-"Me (ED) and [Qualified Professional/Licensee
(QPIL)] is responsible (for the medication
administration process)."

-"|_ am not here every day. | am going between the
2 houses (facilities)."

Interviews between 12/16/2025 and 12/19/2025
with the QP/L revealed:

-"We are having trouble getting our hands on
things (the facility's information) due to the move."
-Was responsible for the medication
administration process for the facility.
-"Sometimes they (doctors) have why they take it
(medications) and sometimes they don't."

Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 11 V 118

If continuation sheet 12 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

-"Prior authorization is needed for the medication
approval (through Medicaid). We could not get
pass through medications (a few days' supply of
medications given by the pharmacy)."

-"| believe it means the med is not given (staff
initials with a circle around it)."

-"| will not typically purchase that (antipsychotic
medications for clients) because insurance will
cover it at 100% and we will not get reimbursed.
We would purchase over the counter medications
like Melatonin."

-"| don't have record of it (documentation of
medications purchased by the facility for the
clients who were out of medications)."
-"Medications should match the MAR, right time,
right client."

-"Staff have been trained and know how to
document medication administration properly."

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 12/19/2025 of Plan of Protection dated
12/19/2025 written by the QP/L revealed:

“What immediate action will the facility take to
ensure the safety of the consumers in your care?
The immediate actions that will be done to ensure
the safety of consumers will be to:

V120: All oral, topical and refrigerated meds will
be kept separate for each client at all times.
V121: All med orders will be closely reviewed to
ensure all required information is listed
(medication, start/discontinuation date, dose,
frequency, reason for client taking med,
physician/prescriber signature, credentials and
date). Med reviews will be completed to ensure
that meds are needed and to discuss any
adverse effects.

Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 12 V 118

If continuation sheet 13 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

All MARs will have detailed information listed for
all meds to include (generic/brand name if
applicable, dose, frequency, route, time to include
(generic/brand name if applicable, dose,
frequency, route, time etc.).

V123: All MARs will be reviewed for accuracy,
physician/prescriber to be contacted to discuss
any adverse effects if meds are refused, out of
stock and/or not given for any reason and clear
documentation of these incidents and contacts
made regarding this.

V118: All meds administered in the facility will
have an associated med order that includes all
pertinent information. All MARs will be
documented on correctly and reviewed for
accuracy.

Describe your plans to make sure the above
happens.

On 12/19/25 a staff memo will be sent requiring
signature/date acknowledgement that they are
aware of how to handle med errors, med
documentation, storage of meds, required
information for med orders if/when taking clients
to appts and meds are added and/or changed.
They will also be reminded of required
information that should be on all MARs, who to
contact if meds are out, not given or refused.
V120: Additional lock boxes have been ordered
and will be delivered to the facility between
7a-11a on 12/20 (2025). Staff will ensure that any
topical/oral meds that are stored together are
seperated at all times. On 12/18/25 ED & QP
(QP/L) reviewed med boxes and only oral meds
are in lock boxes at this time.

V121: On 12/15/25 QP (QP/L) created a
physician/prescriber order form that will be
included in all new client intake packets and
copies provided to the ED and additional copies
to be included in client packets that are locked in
the van for access when taking clients to appts.
Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 13 V 118

If continuation sheet 14 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 14 V 118

6mo review appts will be scheduled for all clients
to ensure that meds are reviewed by a physician
and/or pharmacist. Providers will be notified
within 24hrs if a med is out of stock, PA
(Physician Assistant) is needed, med is refused
and/or not given for any reason to inquire about
adverse effects of the client not having a med. If
awaiting for a med refill/PA or anything else that
would prohibit the client from receiving meds the
ED has been instructed to inquire with the
pharmacy about receiving a limited supply that
can be paid for by the facility until all issues are
resolved and covered by medicaid.

V118 & V123: ED will closely review MARs
weekly for accuracy and notify the QP (QP/L) (via
text or email) and all staff (via [Electronic
communication portal]) of any issues
immediately. ED & QP (QP/L) will ensure that all
incident reports are completed. ED & QP (QP/L)
will ensure that all clients admitted have med
orders that are included on the facilities physician
order form. ED & QP (QP/L) will make regular
contact with providers and/or pharmacy to ensure
all clients have their needed meds."

The facility served clients diagnosed with Conduct
Disorder, Oppositional Defiant Disorder,
Posttraumatic Stress Disorder, Anxiety Disorder,
and Borderline Intellectual Functioning Disorder.
Staff administered medications to Clients #1, #2,
and FCs' #3, #4, #5, and #6 without physician
orders. There was a total of 54 combined missing
physician orders for all clients. Clients #1, #2, and
FCs #3, #4, #5, and #6 had a combined total of
336 medication doses not administered and
documented with an X or circle around staff
initials. Client #1, FCs #3, #4, #5, and #6 hada
combined total of 310 medication doses with no
staff initials for administration. Client #1, FCs' #3,
#5, and #6 medications were not available at the
Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 15 of 48

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 15 V 118

facility for administration 40 times combined.
Client #1, FCs #3, #4, #5 and #6 had a combined
total of 121 MAR medication transcription errors.
Client #1's internal and external medications were
not kept separately. This deficiency constitutes a
Type A1 rule violation for serious neglect and
must be corrected within 23 days.

V 120] 27G .0209 (E) Medication Requirements V 120
10A NCAC 27G .0209 MEDICATION

REQUIREMENTS

(e) Medication Storage:

(1) All medication shall be stored:

(A) in a securely locked cabinet in a clean,

well-lighted, ventilated room between 59 degrees

and 86 degrees Fahrenheit;

(B) in a refrigerator, if required, between 36

degrees and 46 degrees Fahrenheit. If the

refrigerator is used for food items, medications

shall be kept in a separate, locked compartment

or container;

(C) separately for each client;
(D) separately for external and internal use;

(E) in a secure manner if approved by a physician
for a client to self-medicate.
(2) Each facility that maintains stocks of
controlled substances shall be currently
registered under the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

This Rule is not met as evidenced by:
Based on record review, observation and
interviews, the facility failed to ensure internal and

Division of Health Service Regulation

STATE FORM 6899 1QK511

If continuation sheet 16 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 120] Continued From page 16 V 120

external medications were stored separately
affecting 1 of 2 Current Clients (#1). The findings
are:

Review on 12/04/2025 of Clien
revealed:

There were no physician's orders for:

-Albuterol Hydrofluoroalkane (HFA) 90 Microgram
(MCG) Inhaler (Asthma)- Inhale two puffs four
times daily as needed for wheezing or shortness
of breath.
-Hydrocortisone 2.5% Ointment (Irritation)- Apply
topically twice daily as needed for anal irritation.

#1's record

Observation on 12/04/2025 at approximately 3:14
pm of Client #1's medication box revealed:
-Hydrocortisone; a medication for external use
and Albuterol; a medication for internal use were
stored in a plastic bag together.

Interview on 12/19/2025 with the Qualified
Professional/Licensee revealed:

-"We ordered new med (medication) boxes to
store those (external and internal meds)
separately and this will be included in the staff
memo as a reminder."

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.

V 121} 27G .0209 (F) Medication Requirements v 121
10A NCAC 27G .0209 MEDICATION

REQUIREMENTS

(f) Medication review:

(1) If the client receives psychotropic drugs, the
governing body or operator shall be responsible

Division of Health Service Regulation

STATE FORM 6899

1QK511

If continuation sheet 17 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

for obtaining a review of each client's drug
regimen at least every six months. The review
shall be to be performed by a pharmacist or
physician. The on-site manager shall assure that
the client's physician is informed of the results of
the review when medical intervention is indicated.
(2) The findings of the drug regimen review shall
be recorded in the client record along with
corrective action, if applicable.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to obtain drug regimen reviews every
six months for 1 of 2 Clients (#1) who received
psychotropic drugs. The findings are:

Review on 12/04/2025 of Client #1's record
revealed:
-Physician's order dated 12/10/2024 for:

-Aripiprazole 5 milligrams (mg) (Disruptive Mood
Dysregulation Disorder)- Take 1 tablet (tab) by
mouth at bedtime.

There was no physician order for:

-Dyanavel ER (Extended Release) 5 mg
(Antipsychotic)- Take 1 tab by mouth every
morning.

-There was no evidence of a current six-month
drug regimen review for Client #1.

-There was no documentation of a current
six-month drug regimen review for Client #1.

Reviews between 12/04/2025 and 12/16/2025 of
Client #1's MARs from 06/01/2025 - 11/25/2025
revealed:

-Staff documented Client #1 was administered
the above medications from 06/01/2025 -

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 121] Continued From page 17 v 121

If continuation sheet 18 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 121] Continued From page 18 Vv 121

11/25/2025.

Interview on 12/19/2025 with the Qualified
Professional/Licensee revealed:

-She was not aware of the six-month client drug
regimen review requirement.

-She confirmed that Client #1 had not received a
six-month drug regimen review by a pharmacist
or physician.

-"The Executive Direct
six-month review with
pharmacist."

‘or (ED) will schedule the
the physician or

Interview on 12/08/2025 with the ED revealed:
-She was not aware of the six-month client drug
regimen review requirement.

-She confirmed that Client #1 had not received a
six-month drug regimen review by a pharmacist
or physician.

-"We have not done that (ensured the completion
of a six-month drug regimen review by physician
or pharmacist for Client #1)."

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.

V 123} 27G .0209 (H) Medication Requirements V 123
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 6899

1QK511

If continuation sheet 19 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
acility failed to ensure all medication
administration errors were immediately reported
io a pharmacist or physician affecting 2 of 2
Clients (#1 and #2) and 4 of 4 Former Clients (FC
#3, #4, #5, and #6). The findings are:

Finding #1:

Review on 12/04/2025 of Client #1's record
revealed:

The physician orders dated 12/10/2024:
-Aripiprazole 5 milligrams (mg) (Disruptive Mood
Dysregulation Disorder (DMDD))- Take 1 tablet
(tab) by mouth at bedtime.

-Fluoxetine HCL (Hydrochloride) 20 mg
(Antidepressant)- Take 1 tab by mouth every day
in the morning.

-Clonidine .2 mg (Attention Deficit Hyperactivity
Disorder (ADHD))- Take 1 tab by mouth twice
daily.

-Atomoxetine 100 mg (ADHD)- Take 1 capsule
(cap) by mouth every morning.

-Melatonin 10 mg (Sleep Aid)- Take 1 tab by
mouth at bedtime.

-Hydroxyzine 50 mg (Antidepressant)- Take 1
tab by mouth every morning.

-Trazodone 100 mg (Sleep Aid)- Take 1 tab by
mouth at bedtime.

-Omeprazole 20 mg (Acid Reflux)- Tab 1 cap by
mouth every morning.

-Azstarys 52.3 mg-10.4 mg (ADHD)- Give 1 cap
Division of Health Service Regulation
STATE FORM

6899 1QK511

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

DEFICIENCY)
V 123] Continued From page 19 V 123

If continuation sheet 20 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

by mouth every morning.
There were no physicians' orders for:

-Dyanavel ER (Extended Release) 5 mg
(Antipsychotic)- Take 1 tab by mouth every
morning.

-Cetirizine 10 mg (Allegeries)- Take 1 tab by
mouth every day.

-Albuterol Hydrofluoroalkane (HFA) 90
Microgram (MCG) Inhaler (Asthma)- Inhale 2
puffs four times daily as needed for wheezing or
shortness of

breath.

-Hydrocortisone 2.5% Ointment (Irritation)-
Apply topically twice daily as needed for anal
irritation.

-Ventolin HFA (Asthma)- Inhale 2 puffs by mouth
every 4 hours as needed for wheezing/shortness
of breath.

-Polyethylene Glycol 3350 (Constipation)- Mix
17 GM in 8 oz of water or juice and drink daily as
needed for constipation.

Reviews between 12/04/2025 and 12/16/2025 of
Client #1's MARs from 06/01/2025 - 11/30/2025
revealed:

A.

There were no staff initials for administration:
-Melatonin 10 mg at 7 pm on 09/08/2025.
-Omeprazole 20 mg at 7 am on 08/01/2025,
08/09/2025, 08/14/2025, 10/24/2025, 11/04/2025
and 11/06/2025.

-Trazodone 100 mg at 7 pm on 6/21/2025.
-Azstarys 52.3-10.4 mg at 7 pm on 06/22/2025
and 06/23/2025.

-Hydroxyzine 50 mg at 7am 07/22/2025 and
08/01/2025.

Client #1 had a total of 12 medication doses with
no staff initials for administration.

B.

Division of Health Service Regulation
STATE FORM

6899 1QK511

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

DEFICIENCY)
V 123] Continued From page 20 V 123

If continuation sheet 21 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
V 123] Continued From page 21 V 123

There was an "X= Not Given" and/or circle
around staff initials specifying medications were
not administered for:

-Azstarys 52.3-10.4 mg at 7 pm on 07/01/2025,
07/15/2025, 07/20/2025, 07/25/2025, 07/26/2025,
07/27/2025, 07/28/2025, 07/29/2025, 09/01/2025,
09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025,
09/06/2025, 09/07/2025, 09/08/2025 and
09/09/2025.

-Abilify 5 mg at 7 pm on 06/07/2025, 08/02/2025,
08/03/2025, 08/24/2025, 10/10/2025,

10/17/2025, 10/24/2025, 11/06/2025, 11/15/2025,
11/16/2025, 11/19/2025, 11/20/2025 and
11/21/2025.

-Trazodone HCL 100 mg at 7 pm on
06/07/2025,10/10/2025,

10/17/2025, 10/24/2025, 11/06/2025, 11/14/2025,
11/19/2025, and 11/20/2025.

Melatonin 10 mg at 7 pm 06/07/2025,
10/10/2025, 10/17/2025, 10/24/2025, 11/06/2025,
11/14/2025, 11/19/2025 and 11/20/2025.
-Atomoxetine 100 mg at 7 am on 07/01/2025,
07/20/2025, 09/01/2025, 09/02/2025, 09/03/2025,
09/06/2025, 09/08/2025, 09/17/2025, 09/20/2025,
10/01/2025, 10/02/2025, 10/03/2025, 10/04/2025,
10/05/2025, 10/11/2025, 10/25/2025, 11/07/2025,
11/08/2025 and 11/20/2025.

-Dyanavel 5 mg at 7 am on 10/01/2025,
10/11/2025, 10/25/2025,11/07/2025, 11/08/2025,
11/11/2025, 11/18/2025, 11/19/2025,
11/20/2025,11/21/2025, 11/22/2025, 11/23/2025,
11/24/2025, and 11/25/2025.

-Cetirizine 10 mg at 7am on 07/01/2025,
07/15/2025, 07/20/2025, 09/06/2025, 09/08/2025,
09/17/2025, 09/20/2025, 10/01/2025, 10/11/2025,
10/25/2025, 11/07/2025, 11/08/2025, 11/11/2025
and 11/20/2025.

- Fluoxetine (Prozac) HCL 20 mg at 7 am on
07/01/2025, 07/15/2025 and 07/20/2025.
-Omeprazole 20 mg at 7 am on 07/01/2025,
Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 22 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
V 123] Continued From page 22 V 123

07/15/2025, 07/20/2025, 09/01/2025, 09/02/2025,
09/03/2025, 09/06/2025, 09/08/2025, 09/17/2025,
09/20/2025, 10/01/2025, 10/02/2025, 10/03/2025,
10/04/2025, 10/05/2025, 10/06/2025, 10/11/2025,
10/25/2025, 11/01/2025, 11/07/2025, 11/08/2025,
11/11/2025 and 11/20/2025.

-Clonidine HCL .2mg at 7 am on 09/06/2025,
09/08/2025, 09/17/2025, 09/18/2025, 09/20/2025,
10/10/2025, 10/11/2025, 10/25/2025; 7 pm on
10/10/2025, 10/17/2025 and 10/24/2025.
-Hydroxyzine 50 mg at 7 am 09/06/2025,
09/08/2025, 09/17/2025, 09/20/2025, 10/01/2025,
10/11/2025, 10/15/2025, 10/25/2025, 11/07/2025,
11/08/2025, 11/11/2025 and 11/20/2025.

Client #1 had a total of 142 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

C.

There was no medication available at the facility
for administration:

-Abilify 5 mg at 7 pm on 08/25/2025, 11/09/2025,
11/11/2025, 11/12/2025, 11/13/2025, 11/14/2025,
11/16/2025, 11/17/2025 and 11/18/2025.
-Cetirizine 10 mg at 7 am on 08/26/2025.
-Fluoxetine 20 mg at 7 am on 08/26/2025.
-Atomoxetine 100 mg at 7 am on 07/09/2025,
08/28/2025, 08/30/2025 and 10/02/2025.
-Azstarys 52.3-10.4 mg at 7 am on 08/30/2025.
Client #1 had a total of 16 medication doses
unavailable at the facility for administration.

Reviews between 12/04/2025 and 12/16/2025 of
the facility's record revealed:

-There was no evidence that Client #1's
pharmacist or physician was immediately notified
about the above medication errors.

Finding #2:

Division of Health Service Regulation
STATE FORM 6899 1QK511 If continuation sheet 23 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Reviews on 12/05/2025 and 12/12/2025 of Client
#2's record revealed:
-Admission date of 10/29/2025.
-Diagnosed with ADHD and Oppositional Defiant
Disorder (ODD).
The Physician's orders dated 09/16/2025:
-Abilify 5 mg (Antipsychotic)- Take 1 tab by
mouth in the morning.
There were no physician orders for:
-Depakote ER 500 mg (Mood Stabilizer)- Take 2
tabs by mouth.
-Trazodone 50 mg (Sleep Aid)- Take 1 tab by
mouth.

Reviews on 12/05/2025 and 12/12/2025 of Client
#2's MARs from 10/29/2025 - 11/30/2025
revealed:

A.

There was an "X= Not Given" for:

-Depakote ER 500 mg at 7 am on 11/24/2025.
There was a circle around staff initials indicating
medications were not administered for:

-Abilify 5 mg at 7 am on 11/04/2025, 11/07/2025,
11/11/2025, 11/14/2025 and 11/20/2025.
-Depakote ER 500 mg at 7 am on 11/04/2025,
11/07/2025, 11/11/2025, 11/14/2025
and11/20/2025.

-Trazodone 50 mg at 7 pm on 11/18/2025,
11/19/2025, 11/20/2025 and 11/28/2025.

Client #2 had a total of 15 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

Reviews on 12/05/2025 and 12/12/2025 of the
facility's record revealed:

-There was no evidence that Client #2's
pharmacist or physician was immediately notified
about the above medication errors.

Finding #3:
Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 123] Continued From page 23 V 123

If continuation sheet 24 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Reviews on 12/08/2025 and 12/12/2025 of FC
#3's record revealed:
-Admission date of 07/18/2025.
-Discharge date of 11/17/2025.
-Diagnosed with ADHD, ODD, and Post
Traumatic Stress Disorder (PTSD).
There were physicians' orders dated 07/16/2025
for:

-Risperidone .5 mg (Aggression)- Take 1 tab by
mouth at bedtime (8 pm).

-Fluoxetine 40 mg (Mood)- Take 1 cap by mouth
in the morning (8 am).

-Magnesium 100 mg (Sleep)- Take 2 tabs by
mouth at bedtime (8 pm).

-Risperidone .25 mg (Aggression)- Take 1 tab
by mouth in the morning (8 am).

-Atomoxetine 80 mg (Focus)- Take 1 cap by
mouth in the morning at (8 am).

-Children's Multivitamin-Immune (Supplement)-
Take 1 tab by mouth at bedtime (8 pm).
There were no physicians’ orders for the following
over-the-counter medications:

-lbuprofen (Pain/Fever Relief).

-MiraLAX (Constipation).

-Tylenol (Pain Relief).

-Clear lax (Constipation).

Reviews on 12/08/2025 and 12/12/2025 of FC
#3's MARs from 08/01/2025 - 11/30/2025
revealed:

A.

There were no staff initial for administration:
-Children's Multivitamin-Immune at 7 pm on
09/18/2025.

FC #3 had a total of 1 medication dose with no
staff initial for administration.

B.
There was an "X= Not Given" and/or circle

Division of Health Service Regulation
STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 24 V 123

If continuation sheet 25 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 25 V 123

around staff initials specifying medications were
not administered for:

-Risperidone .5 mg at 7 pm on 08/10/2025,
09/07/2025, 09/14/2025 and 09/15/2025.
-Fluoxetine 40 mg at 7 am on 08/01/2025,
08/08/2025, 08/12/2025, 08/22/2025, 09/05/2025,
09/12/2025, 09/19/2025, 10/24/2025 and
11/12/2025.

-Magnesium 100 mg at 7 pm on 08/10/2025,
09/14/2025 and 09/15/2025.

-Risperidone .25 mg at 7 am on 08/01/2025,
08/08/2025, 08/12/2025, 08/22/2025, 10/24/2025
and 11/12/2025.

-Atomoxetine 80 mg at 7 am on 08/01/2025,
08/08/2025, 08/12/2025, 08/22/2025, 09/05/2025,
09/12/2025, 09/19/2025, 09/24/2025, 09/26/2025,
10/24/2025 and 11/12/2025.

-Children's Multivitamin-Immune at 7 pm on
08/10/2025, 09/07/2025, 09/14/2025 and
09/15/2025.

FC#3 had a total of 37 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

C.

There were no medications available at the facility
for administration:

-Children's Multivitamin-Immune at 7 pm on
09/27/2025.

-Atomoxetine 80 mg at 7 am on 09/25/2025.
-Magnesium 100 mg at 7 pm on 09/26/2025 and
09/27/2025.

FC #3 had a total of 4 medication doses
unavailable at the facility for administration.

Reviews on 12/05/2025 and 12/12/2025 of the
facility's record revealed:

-There was no evidence that FC #3's pharmacist
or physician was immediately notified about the
above medication errors.

Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 26 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING
NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

SUMMARY STATEMENT OF DEFICIENCIES ID

PROVIDER'S PLAN OF CORRECTION (x5)

Finding #4:

Review on 12/09/2025 of FC #4's record
revealed:
-Admission date of 05/30/2025.
Discharge date of 09/03/2025.
Diagnosed with DMDD, PTSD, Borderline
Intellectual Functioning, ADHD, and Anxiety
Disorder.
There were no physicians' orders for:
-Amantadine HCL 100 mg (ADHD)- Take 1 cap
daily.
-Benztropine 1 mg (Mood Stabilizer)- Take 1 tab
daily.
-Bupropion HCL SR 150 mg (Antidepressant)-
Take 1 tab daily.
-Clonidine HCL .2 mg (ADHD)- Take 1 tab at
bedtime.
-Desmopressin .2 mg (Fluid balance)- Take 1
lab at bedtime.

-Desvenlasfaxine Succinate ER 100 mg
(Antidepressant)- Take 1 tab daily.

-Lamotrigine ER 200 mg (Mood Stabilizer)- Take
1 tab twice daily.

-Lurasidone 60 mg (Antipsychotic)- Take 1 tab in
the in the pm.

-Oxybutynin Chloride 5 mg (Overactive
Bladder)- Take 1 tab at bedtime.

-Cephalexin 500 mg (Antibiotic)- Take 2 times a
day for 7 days.

Reviews on 12/08/2025 and 12/12/2025 of FC
#4's MARS from 08/01/2025 - 08/30/2025
revealed:

A.

There were no staff initials for administration:
-Amantadine HCL 100 mg at 7 am on 08/04/2025
and 08/07/2025 - 08/30/2025.

-Benztropine 1 mg at 7 am on 08/04/2025 and
Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 123] Continued From page 26 V 123

If continuation sheet 27 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

08/07/2025 - 08/30/2025.

-Bupropion HCL SR 150 mg at 7 am on
08/04/2025 and 08/07/2025 - 08/30/2025.
-Clonidine HCL .2 mg at 7 pm on 08/03/2025 and
08/07/2025 - 08/30/2025.

-Desmopressin .2 mg at 7 pm on 08/03/2025 and
08/07/2025 - 08/30/2025.

-Desvenlasfaxine Succinate ER 100 mg at 7 am
on 08/04/2025 and 08/07/2025 - 08/30/2025.
-Lamotrigine ER 200 mg at 7 pm on 08/03/2025
and 7 am on 08/04/2025 and 08/07/2025 -
08/30/2025.

-Lurasidone 60 mg at 7 pm on 08/03/2025 and
08/07/2025 - 08/30/2025.

-Lurasidone 40 mg at 7 am on 08/04/2025 and
08/07/2025 - 08/30/2025.

-Oxybutynin Chloride 5 mg at 7 pm on 08/03/2025
and 08/07/2025 - 08/30/2025.

-Cephalexin 500 mg at 7 am on 08/04/2025,
08/05/2025, 08/06/2025 and at 7 pm on
08/03/2025, 08/05/2025, 08/06/2025 and
08/07/2025.

FC #4 had a total of 275 medication doses with
no staff initials for administration.

B.

There was an "X= Not Given" and/or circle
around staff initials specifying medications were
not administered for:

-Amantadine HCL 100 mg at 7 am on
08/01/2025.

-Benztropine 1 mg at 7 am on 08/01/2025.
-Bupropion HCL SR 150 mg at 7 am on
08/01/2025.

-Desvenlasfaxine Succinate ER 100 mg at 7 am
on 08/01/2025.

-Lamotrigine ER 200 mg at 7 am on 08/01/2025.
-Lurasidone 40 mg at 7 am on 08/01/2025.
-Cephalexin 500 mg at 7 am on 08/01/2025.

FC #4 had a total of 7 medication doses not
Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 27 V 123

If continuation sheet 28 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

administered and documented with an "X=Not
Given" or circle around staff initials.

Reviews on 12/08/2025 and 12/12/2025 of the
facility's record revealed:

-There was no evidence that FC #4's pharmacist
or physician was immediately notified about the
above medication errors.

Finding #5:

Review on 12/09/2025 of FC #5's record
revealed:
-Admission date of 08/26/2025.
-Discharge date of 11/17/2025.
-Diagnosed with DMDD, ADHD, and ODD.
There were no physician orders or discontinue
orders for:

-Clonidine .1 mg (ADHD)- Take 1 tab by mouth
three times daily.

-Atomoxetine 25 mg (ADHD)- Take 1 capsule by
mouth daily.

-Risperidone 2 mg (Antipsychotic)- Take 1 tab
by mouth twice daily.

-Oxcarbazepine 600 mg (Mood Stabilizer)- Take
1 tab by mouth twice daily.

-Melatonin 3 mg (Sleep Aid)- Take 2 tabs by
mouth at bedtime.

-Polyethylene Glycol 3350 (Constipation).

Review on 12/09/2025 of FC #5's MARS from
08/01/2025 - 10/31/2025 revealed:

A.

There were no staff initials for administration:
-Clonidine .1 mg at 7 am on 08/27/2025,
08/28/2025, 08/29/2025, 09/01/2025, and
09/02/2025.

-Risperidone 2 mg at 7 pm on 09/15/2025,
09/19/2025 and 09/21/2025.

-Oxcarbazepine 600 mg at 7pm on 09/17/2025,
Division of Health Service Regulation

STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 28 V 123

If continuation sheet 29 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 29 V 123

09/22/2025, 09/27/2025 and 09/29/2025.
FC #5 had a total of 12 medication doses with no
staff initials for administration.

B.

There was an "X= Not Given" and/or circle
around staff initials specifying medications were
not administered for:

-Atomoxetine 25 mg at 7 am on 09/05/2025,
09/12/2025, 09/19/2025, 09/28/2025, 09/29/2025,
09/30/2025 and 10/24/2025.

-Oxcarbazepine 600 mg at 7 am on 09/05/2025,
09/12/2025, 09/19/2025, 09/28/2025, 09/29/2025,
and 09/30/2025; 7 pm on 09/07/2025,
09/14/2025, 09/15/2025, 09/28/2025, 09/30/2025
and 10/24/2025.

-Clonidine .1 mg at 7 am on 09/05/2025,
09/12/2025 and 09/19/2025; 1 pm on 09/07/2025,
09/14/2025, 09/15/2025 and 10/24/2025.
-Risperidone 2 mg at 7 am on 09/05/2025,
09/12/2025, 09/19/2025 and 10/24/2025; 1 pm on
09/07/2025, 09/14/2025, 09/28/2025, and
09/30/2025; 7 pm on 09/07/2025, 09/14/2025,
09/30/2025 and 10/24/2025.

FC #5 had a total of 38 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

Cc.

There were no medications available at the facility
for administration:

-Melatonin 3 mg at bedtime on 08/28/2025,
08/30/2025, 09/01/2025 and 09/02/2025.
-Oxcarbazepine 600 mg at 7 am on 10/01/2025
and 10/02/2025.

-Clonidine .1 mg at 7 am on 10/02/2025, 3 pm on
10/01/2025, 7 pm on 10/01/2025.

-Risperidone 2 mg at 7 am on 10/01/2025,
10/02/2025, 10/03/2025; 3 pm on 10/01/2025,
10/02/2025 and 10/03/2025.

Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 30 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

-Atomoxetine 25 mg at 7 am on 10/01/2025 and
10/02/2025.

FC #5 had a total of 17 medication doses
unavailable at the facility for administration.

Review on 12/09/2025 of the facility's record
revealed:

-There was no evidence that FC #5's pharmacist
or physician was immediately notified about the
above medication errors.

Finding #6:

Review on 12/15/2025 of FC #6's record
revealed:
-Admission date of 07/31/2024.
-Discharge date of 09/04/2025.
-Diagnosed with PTSD and Adjustment Disorder.
There were physician orders dated 04/16/2025
for:

-Hydroxyzine HCL 50 mg (Antidepressant)- Take
1 tab by mouth every day at bedtime.

-Melatonin 5 mg (Sleep Aid)- Take 1 tab by
mouth daily in the evening.

-Propranolol HCL 20 mg (Mood Stabilizer)- Take
1 tab by mouth 2 times per day.

-Sertraline HCL 100 mg (Anxiety)- Take 1 tab by
mouth daily in the am.
There was no physician orders for:

-Cetirizine HCL 10 mg (Allergies)- Take 1 tab by
mouth.

Review on 12/17/2025 of FC #6's MARS from
03/01/2025 - 08/31/2025 revealed:

A.

There were no staff initials for administration:
-Hydroxyzine HCL 50 mg at 7 pm on 04/21/2025,
7/19/2025 and 07/21/2025.

-Melatonin 5 mg at 7 pm on 04/21/2025,
06/21/2025 and 07/21/2025.

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 123] Continued From page 30 V 123

If continuation sheet 31 of 48

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL013-212

ADRIENNE'S HOUSE

PRINTED: 01/14/2026

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B. WING _______________________ 12/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
CONCORD, NC 28025

-Propranolol HCL 20 mg at 7 am on 04/04/2025
and 7 pm on 04/09/2025.

-Cetirizine HCL 10 mg at 7am on 04/04/2025.
-Sertraline HCL 100 mg at 7 am on 04/04/2025.
FC #6 had a total of 10 medication doses with no
staff initials for administration.

B.

There was an "X= Not Given" and/or circle
around staff initials specifying medications were
not administered for:

-Hydroxyzine HCL 50 mg at 7 am on 05/16/2025,
05/17/2025, 05/23/2025, 05/30/2025; 7 pm on

04/13/2025, 04/14/2025, 04/16/2025, 04/17/2025,
04/18/2025, 04/19/2025, 04/20/2025, 04/24/2025,
04/25/2025, 04/26/2025, 04/28/2025, 04/30/2025,
05/04/2025, 05/11/2025, 06/22/2025, 07/06/2025,

07/12/2025, 07/13/2025 and 08/10/2025.
-Melatonin 5 mg at 7 pm on 04/13/2025,

04/14/2025, 04/16/2025, 04/17/2025, 04/18/2025,
04/19/2025, 04/20/2025, 04/24/2025, 04/25/2025,
04/26/2025, 04/28/2025, 04/30/2025, 06/22/2025,

06/23/2025, 07/12/2025, 07/13/2025 and
08/10/2025.
-Propranolol HCL 20 mg at 7 am on 03/03/2025,

03/04/2025, 03/26/2025, 03/29/2025, 05/16/2025,

05/17/2025, 05/23/2025, 05/30/2025; 7 pm on

04/13/2025, 04/14/2025, 04/16/2025, 04/17/2025,
04/18/2025, 04/19/2025, 04/20/2025, 04/24/2025,
04/25/2025, 04/26/2025, 04/28/2025, 04/30/2025,
05/04/2025, 05/11/2025, 06/22/2025, 06/26/2025,

07/12/2025, 07/13/2025, 08/01/2025, 08/12/2025
and 08/22/2025.
-Sertraline HCL 100 mg at 7 am on 06/06/2025,

06/13/2025, 06/19/2025, 06/22/2025, 06/23/2025,

06/24/2025, 06/27/2025, 06/28/2025,08/01/2025,
08/12/2025 and 08/22/2025.
-Cetirizine HCL 10 mg at 7am 03/15/2025,

03/16/2025, 03/17/2025, 03/26/2025, 03/29/2025,
06/06/2025, 06/13/2025, 06/19/2025, 06/22/2025,

Division of Health Service Regulation
STATE FORM

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

DEFICIENCY)
V 123] Continued From page 31 V 123

6899

1QK511 If continuation sheet 32 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

06/23/2025, 06/24/2025, 06/27/2025, 06/28/2025,
08/01/2025, 08/12/2025, 08/27/2025 and
08/29/2025.

FC #6 had a total of 97 medication doses not
administered and documented with an "X=Not
Given" or circle around staff initials.

C.

There were no medications available at the facility
for administration:

-Melatonin 5 mg at 7 pm on 06/24/2025.
-Centrizine HCL 10 mg at 7am on 08/26/2025 and
08/28/2025.

FC #6 had a total of 3 medication doses
unavailable at the facility for administration.

Review on 12/09/2025 of the facility's record
revealed:

-There was no evidence that FC #6's pharmacist
or physician was immediately notified about the
above medication errors.

Interview on 12/19/2025 with the Qualified
Professional/Licensee revealed:

-Did not notify the pharmacist or physican about
the facility's medication errors.

-"The physician will be notified if a client has not
had a med (medication) or refused a med. This
will be documented and we will follow the
provider's instruction."

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.

V 295} 27G .1703 Residential Tx. Child/Adol - Req. forA | V 295

P

Division of Health Service Regulation

STATE FORM 6899

1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 32 V 123

If continuation sheet 33 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS

(a) In addition to the qualified professional
specified in Rule .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 10A
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). Ata minimum these
policies shall address the following:

(1) 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 review and interviews, the
facility failed to employ an Associate Professional
(AP) who provided services to the facility on a
full-time basis. The findings are:

Review on 12/04/2025 of the facility's Client and
Staff Census form revealed:

-There was no AP listed as a current
employee/staff.

-The Former AP was listed as a former
employee/staff.

Review on 12/16/2025 of the Former AP's

Division of Health Service Regulation
STATE FORM

6899 1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 295| Continued From page 33 V 295

If continuation sheet 34 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 295| Continued From page 34 V 295

personnel record revealed:

-Date of Hire: 12/03/2024.

-Separation date: 11/07/2025.

-There was a AP Job description signed and
dated 09/08/2025 by the Former AP.

nterview on 12/08/2025 with Staff #2 revealed:
-"| think she (AP) left in November (2025)."

nterview on 12/16/2025 with the Former AP
revealed:

-She resigned as the AP for the facility in
November (2025).

nterviews on 12/05/2025 and 12/19/2025 with the
Qualified Professional/Licensee revealed:

-"My AP (Former AP) just quit not that long ago (2
io 3 weeks ago)."

-"| have extended an offer (employment offer for
he AP position) and it has been accepted."

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

Staffing

410A NCAC 27G .1704 MINIMUM STAFFING
REQUIREMENTS

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

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

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

(3) four direct care staff shall be present for

Division of Health Service Regulation
STATE FORM

6899 1QK511

If continuation sheet 35 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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.

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

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

This Rule is not met as evidenced by:

Based on observation and interviews the facility
failed to ensure the minimum staffing ratio of 2
staff for up to 4 adolescents while they are asleep
or awake. The findings are:

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 296 | Continued From page 35 V 296

If continuation sheet 36 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 296 | Continued From page 36 V 296

Observation on 12/04/2025 at approximately 2:49
pm revealed:

-Staff #2 entered the facility with Clients' #1 and
#2.

Interview on 12/04/2025 with Client #1 revealed:
-"There used to be only 1 (staff), but since we got
more people we got like 3 staff now. There are
usually 2 or 3 staff here."

Interview on 12/04/2025 with Client #2 revealed:
-"When there were 3 kids (Clients) here there

was 3 (staff), but now that there are 2 kids there
is 2 staff."
-"At night-time there is 2 (staff)."

Interview on 12/16/2025 with the Former
Associate Professional revealed:

-"It is supposed to be 2 staff at all times."
-"There have been situations where there has
been only 1 staff."

Interview on 12/19/2025 with the Qualified
Professional/Licensee revealed:

-"We will ensure that we have 2 staff transporting
clients unless it is stated otherwise in their plan of
care."

V 366} 27G .0603 Incident Response Requirements V 366
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

Division of Health Service Regulation
STATE FORM

6899 1QK511

If continuation sheet 37 of 48

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-212

ADRIENNE'S HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
CONCORD, NC 28025

PRINTED: 01/14/2026

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 12/19/2025

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

DEFICIENCY)
V 366 | Continued From page 37 V 366

of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective
measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart |.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

review team within 24 hours of the incident. The

Division of Health Service Regulation
STATE FORM

6899 1QK511 if continuation sheet 38 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

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

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

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

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 366 | Continued From page 38 V 366

If continuation sheet 39 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

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

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

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

Reviews on 12/04/2025 and 12/08/2025 of the
facility's incident reports from 06/01/2025 -
11/25/2025 revealed:

-6/09/2025; Former Client (FC) #7's AWOL
(absence without leave) with police contact
incident.

-6/17/2025; FC #8's aggressive behavior with
police contact incident.

-6/21/2025; FC #7's AWOL with police contact
incident.

-6/20/2025; FC #7's aggressive behavior with
police contact incident.

-08/03/2025; FC #4's refusal of medications
incident.

-08/28/2025; FC #5's medications unavailable for
administration incident.

-08/29/2025; FC #5's medications unavailable for
administration incident.

-08/30/2025; FC #5's medications unavailable for
administration incident.

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 366 | Continued From page 39 V 366

If continuation sheet 40 of 48

PRINTED: 01/14/2026
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: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 40 V 366

-08/31/2025; FC #5's medications unavailable for
administration incident.
-09/02/2025; FC #5's medications unavailable for
administration incident.
-09/18/2025; FC #5's verbal altercation,
destruction of staff's property and physical
restraint incident.
-09/22/2025; FC #5's physical altercation with FC
#3 incident.
-09/22/2025; FC #3's physical assault on staff
incident.
-09/24/2025; FC #3's medication unavailable for
administration incident.
-09/25/2025; FC #3's medication unavailable for
administration incident.
-09/26/2025; FC #3's medication unavailable for
administration incident.
-09/28/2025; FC #5's medications unavailable for
administration incident.
-09/29/2025; FC #5's medications unavailable for
administration incident.

-10/05/2025; FC #5's missed medication dose
incident.

-10/12/2025; FC #10's property destruction and
physical escort incident.

-11/06/2025; FC #5's medication unavailable for
administration incident.
-11/03/2025; FC #9's medication refusal incident.
-11/09/2025; Client #1's medication unavailable
for administration incident.
-11/10/2025; Client #1's medication unavailable
for administration incident.
-11/10/2025; FC #9's verbal aggression and
property destruction incident.
-11/11/2025; FC #9's medication refusal incident.
-11/12/2025; Client #1's medication unavailable
for administration incident.
-11/13/2025; Client #1's medication unavailable
for administration incident.
-11/15/2025; FC #9's medication refusal incident.
Division of Health Service Regulation

STATE FORM ad 1QK511 If continuation sheet 41 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL013-212
NAME OF PROVIDER OR SUPPLIER

ADRIENNE'S HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW
CONCORD, NC 28025

PRINTED: 01/14/2026

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 12/19/2025

-11/16/2025; Client #1's medication unavailable
or administration incident.
-11/18/2025; Client #1's medication unavailable
or administration incident.
-11/18/2025; Client #1's physical altercation with
Client #2 incident.
11/19/2025; Client #1's medication unavai
or administration incident.
-11/21/2025; Client #1's medication unavaii
or administration incident.
-11/24/2025; Client #2's medication unavaii
or administration incident.
11/26/2025; Client #1's medication unavai
or administration incident.

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Reviews on 12/04/2025 and 12/08/2025 of the
acility's records revealed:
There was no Risk Cause Analysis (RCA)
documentation for the above incidents from
06/01/2025 - 09/29/2025 to demonstrate how the
acility:

-Attended to the health and safety needs of the
individuals involved in the incident.

-Determined the cause of the incident.

-Developed/implemented corrective measures.

-Developed/implemented measures to prevent
similar incidents.

-Assigned persons to be responsible for
implementation of the corrections and preventive
measures.

Interview on 12/19/2025 with the Qualified
Professional (QP)/Licensee (L) revealed:

-"| will review the rule to ensure | have
understanding of the requirement, and | will
create an updated incident report to ensure the
seven aspects are addressed adequately."

Interview on 12/08/2025 with the Executive
Director revealed:

Division of Health Service Regulation

STATE FORM

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 41 V 366

6899 If continuation sheet 42 of 48

1QK511

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY

STATE FORM 6899

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 120 TODD DRIVE NW
ADRIENNE'S HOUSE CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 42 V 366
-"[QP/L] handles all of that. | am not aware (of the
RCA rule requirement for incidents)."
V 367| 27G .0604 Incident Reporting Requirements V 367

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

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

information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

(1) the provider has reason to believe that
information provided in the report may be

Division of Health Service Regulation

1QK511

If continuation sheet 43 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

erroneous, misleading or otherwise unreliable; or
(2) he provider obtains information
required on the incident form that was previously
unavailable.

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

(1) hospital records including confidential
information;
(2) reports by other authorities; and

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM 6899

1QK511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 43 V 367

If continuation sheet 44 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

(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 II 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 as required and failed to
submit to the LME/MCO upon request other
information regarding the incident. The findings
are:

Review on 12/04/2025 of the facility's incident
reports from 06/01/2025 - 11/25/2025 revealed:
The following IRIS reports had the incomplete
submission code "1/1/0001":

-6/09/2025; Former Client (FC) #7's AWOL
(absence without leave) with police contact
incident.

-6/17/2025; FC #8's aggressive behavior with
police contact incident.

-6/21/2025; FC #7's AWOL with police contact
incident.

-6/20/2025; FC #7's aggressive behavior with
police contact incident.

Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 367 | Continued From page 44 V 367

If continuation sheet 45 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

Reviews on 12/04/2025 of IRIS revealed:
-There was no IRIS reports submitted in the IRIS
system for the above incidents.

Review on 12/04/2025 of an IRIS Report dated
11/27/2025 for FC #6 revealed:

-The incident occurred on 11/24/2025.

-The provider learned of the incident on
11/24/2025.

-LME/MCO comments dated 11/27/2025: "Please
resubmit within 5 days of the date of this
notification."1. Upload DSS Disposition letter
regardless of whether or not DSS opts to
investigate this allegation; 2. Upload copy of
internal investigative report upon completion; 3.
What steps have been taken or protocols put in
place to ensure situations such as this do not
occur and/or to eliminate the possibility of male
staff being in situations where such allegations
can be made?"

-The facility partially updated the IRIS report at
the request of the LME/MCO on 7/27/2025:
"Incident report re-submitted to include completed
investigation report for HCPR staff allegation.
Corrected facility name from [A Sister Facility] to
Adrienne's House which is the accurate facility
name for this report."

Interview on 12/19/2025 with the Qualified
Professional (QP)/Licensee (L) revealed:

-"| will double check the submission of all IRIS
reports. | will ensure that | follow-up with
LME/MCO to make sure | am not missing any of
the information."

Interview on 12/08/2025 with the Executive
Director revealed:

-"[QP/L] handles all of that (IRIS reports
submissions and follow-ups). She handles a
majority of the paperwork."

Division of Health Service Regulation

STATE FORM

6899 1QK511

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

DEFICIENCY)
V 367 | Continued From page 45 V 367

If continuation sheet 46 of 48

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/14/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/19/2025

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
was not maintained in a clean, attractive, and
orderly manner. The findings are:

Observation on 12/04/2025 at approximately
12:40 pm - 12:50 pm of the facility revealed:
Client #1's bedroom:
-A plastic nightstand with a broken frame and 4
dressers stacked upright on the floor.

Client #1's closet:

-A black dresser with a broken frame.
nterview on 12/04/2025 with Client #1 revealed:
-Another client broke the dressers in his room.
-The dresser had been broke for a long period of
ime.

nterview on 12/08/2025 with Staff #2 revealed:
-Client #1's dresser has been broken since the
acility re-opened.
-"So, about 2 weeks max (maximum). That's like
his fourth dresser that needed to be replaced."

nterview on 12/19/2025 with the Qualified
Professional/Licensee revealed:
-"We will make sure we replace everything as

Division of Health Service Regulation

STATE FORM 6899

1QK511

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

DEFICIENCY)
V 367 | Continued From page 46 V 367
This deficiency constitutes a recited deficiency.
V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736

If continuation sheet 47 of 48

PRINTED: 01/14/2026

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
R
MHL013-212 B. WING 12/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 47 V 736

soon as possible once management is made
aware."

Division of Health Service Regulation
STATE FORM 6899 1QK511 If continuation sheet 48 of 48

inspection_type: MHLCS Annual  Complaint and Follow-up