summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(x1) PROVIDER/SUPPLIER/CLI,
IDENTIFICATION NUMBER

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

B WING

MHL013-240 08/11/2025

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES i) PROVIDER'S PLAN OF CORRECTION (x8)
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)
Vv 000 Vv 000
INITIAL COMMENTS

An annual survey was completed on 8/11/25.
Deficiencies were cited.

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

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

V114 Vv 114 08/11/2025 an
27G .0207 Emergency Plans and Supplies

10A NGAG 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 DHSR-MH Licensure Sect
emergencies.
(d) Each facility shall have a first aid kit

accessible for use.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to The agency will conduct fire/disaster drills

ensure fire and disaster drills were conducted monthly and quarterly, alternating shifts to
quarterly and on each shift. The ensure the rule is met.

PRINTED: 08/22/2025
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Division of Health Service Regulation

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

STATE FORM. 898 AKI11 If continuation sheet_1 of 13

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA| (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. AJBORUDING:

COMPLETED

B. WING

MHL013-240 08/11/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

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

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

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

Division of Health Service Regulation

STATE FORM cone 4K If continuation sheet 2 of 14

Division of Health Service Regulation

V 114 Continued From page 1

findings are:
Review on 7/31/25 of the facility's fire and

revealed:
3rd quarter (July- September 2024):

4th quarter (October- December 2024):

1st quarter (January- arch 2025):
No 3rd shift fire and disaster drills;

weekend (8am-8pm) shift disaster drills.

2nd quarter (April- June 2025):

drills;

Interview on 7/30/25 with Client #1 revealed:

Denied completing fire and disaster drills since

admitted in facility May 2025.

Interview on 7/30/25 with Client #2 revealed:

fire.

Denied knowing where to go if there

Interview on 7/30/5 with Client #3 revealed: -

Denied fire and disaster drill since admitted in

July 2025.

disaster drill log from July 1, 2024-June 30, 2025

No 1st shift (8am-3pm) disaster drills;
No 3rd shift (11pm-8am) fire and disaster

drills;

- No weekend (8am-8pm) shift fire and disaster
drills;

- No weekend (8pm-8am) shift fire and disaster
drills.

No ‘st shift and 3rd shift fire and disaster
drills;- No weekend (8am-8pm) shift disaster drills.

No weekend (8pm-8am) shift fire drills;- No

No 1st and 3rd shift fire and disaster drills;
No 2nd shift (3pm-11 pm) disaster drills;
No weekend shift (@am-8pm) fire and disaster

No weekend shift (8pm-8am) disaster drills.

Denied completing fire and disaster drills;

ee

Vv 114

was a

PRINTED: 08/22/2025
FORM APPROVED

(x1)
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

|

MHL013-240

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

PROVIDER/SUPPLIER/CLIA

A BUILDING:

B WING

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

CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

08/11/2025

Division of Health Service Regulation
STATE FORM

SKi11

If continuation sheet 3 of 14

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

(X4) 1D
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 8)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V114

. V114
Continued From page 2

Interview on 7/30/25 with Staff #1 revealed: - "No
fire and disaster drills are being completed.”

Interview on 7/31/25 with Staff #2 revealed:

- Completed fire and disaster drills:

- House Manager/Associate Professional and
staff on duty were responsible for completing the drills;
- Completed a fire and disaster drill last month.

Interview on 7/31/25 with Staff #3 revealed:
- "| never done one (fire and disaster drill) since
| been there," February 2025.

Interview on 8/7/25 with Staff #6 revealed:

- Completed fire and disaster drills once a
month;

- Participated in fire and disaster drills;

- Completed a fire and disaster drill last month.

Interview on 7/31/25 with the House
Manager/Associate Professional revealed:

- Was responsible for completing fire and
disaster drills;

- Was not completing fire and disaster drills;-
Planned to complete a fire and disaster drill on
7131125.

Interview on 7/29/25 with the Qualified

Professional revealed:

- There were several shifts (1st-8am-3pm, 2nd
3pm-11pm, 3rd 11pm-8am, weekend 8am-8pm and
8pm-8am) in the facility;

- House Manager/Associate Professional was
responsible for fire and disaster drills;

- "We will start completing a drill every month.”

Interview on 8/11/25 with the Human Resource
and Compliance Consultant revealed:
- House Manager/Associate Professional was

STATEMENT OF DEFICIENCIES: (x1) PROVIDERYSUPPLIER/CLIA| (K2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A BUILDING

B. WING
MHL013-240 08/11/2025

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

Division of Health Service Regulation

STATE FORM

=n 4KII11 If continuation sheet 4 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION xs)
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)

V114 V 114
Continued From page 3
responsible for completing fire and disaster drills
or assigning various staff to complete the drills; -
Received fire and disaster drills on a spread
sheet after they are documented on an
electronic form.

V 118 27G .0209 (C) Medication Requirements V 118

10A NCAG 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 shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;

(D) date and time the drug is administered; and

(E) name or initials of person administering the drug.
(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR

file followed up by appointment or consultation

with a physician.

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

B WING
MHLO013-240 08/11/2025

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

§50 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

Division of Health Service Regulation
STATE FORM = 411 If continuation sheet 5 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

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

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

New and current staff will be trained and/or August 13
tina dics 2025, and

retraine: to ensure medications are ongoing

administered correctly to residents in care.

MARs will be checked daily to ensure that

medication has been administered, and staff

have signed/initialed and documented

Continued From page 4

properly per the medication orders or

discontinuation orders. Medication training

This Rule is not met as evidenced by: Based on will be scheduled with a qualified person

record reviews, observation and interviews, the privileged to prepare and administer
facility failed to keep the MAR current for 2 of 3 medications on Wednesday, August 13, 2025.
clients (#1, #2) and failed to ensure 6 of 6 audited
paraprofessional staff had been trained in Training was completed by and RN on the
medication administration by a registered nurse, scheduled date for all staff currently employed
pharmacist or other legally qualified person and 1 by the facility.

of 1 Qualified Professional (QP) failed to . .

demonstrate competency. The findings are:
Finding #1 STATE OF GEORGIA
Review on 7/31/25 of Client #1's record revealed:
- Admission date 5/2/25;

- Age 13 years old;

- Diagnoses Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder;

m Physician's order 3/9/25 Tri-Mili 28 (birth
control) tablet, take one tablet by mouth every day; 0 ts
3/17/25 Topiramate (headaches) 100 mg ee
(milligram), take one tablet by mouth every day;
5/5/25 Aripiprazole (depression) 10mg, take one
tablet by mouth every day;

5/11/25 Denta 5000 Plus cream (fluoride
toothpaste), apply thin ribbon to toothbrush and
brush thoroughly once daily for 2 minutes
preferably at bedtime in place of regular
toothpaste;

7/9/25 Escitalopram (antidepressant) 5mg tablet,
take one tablet by mouth every day.

Review on 7/29/25 of Client #1's MARs from May
2, 2025-July 29, 2025 revealed:
- No staff initials for administration for

STATEMENT OF DEFICIENCIES (xt) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A BUILDING
B WING
MHL013-240 08/11/2025

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

§50 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027

Division of Health Service Regulation
STATE FORM ad AKIN If continuation sheet 6 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 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)

Vis Continued From page 5 wine
Escitalopram 5mg tablet; Tri-Mili 28 tablet on
5/29;
- No staff initials for administration for
Aripiprazole 10mg on 6/10, 6/13, 6/29;
- No staff initials for administration for
Topiramate
100mg on 6/10, 6/13;
- Denta 5000 Plus cream was not listed on the
MAR for May and June.

Review on 7/31/25 of Client #2's record revealed:

- Admission date 2/9/25;

- Age 17 years old;

- Diagnoses Major Depressive Disorder, Post
Traumatic Stress Disorder (PTSD), Conduct
Disorder, Generalized Anxiety Disorder;

- Physician's Orders 2/10/25 Chlorpromazine
(antipsychotic) HCL (hydrochloride) 50mg, take one
tablet by mouth at bedtime; Guanfacine ER (extended
release) (nonstimulant) 2mg, take one tablet by mouth
at bedtime; Benztropine Mesylate (muscle control)
11mg, take one tablet by mouth at bedtime;
Triamcinolone (dermatitis) 0.1% cream, apply 1
application on the skin twice a day to affected area;
Risperidone (antipsychotic) 2mg, take one tablet by
mouth daily; Lamotrigine (major depression) 25 mg,
take two tablets by mouth daily; Melatonin (sleep aid)
5mg, take one tablet by mouth at bedtime;
Levonorgestrel-Ethiny! Estradiol (birth control)
0.2mg, take one tablet by mouth every day;

3/15/25 Prazosin HCL (PTSD) 2mg take one
capsule by mouth every night;

6/10/25 Fluoxetine HCL (antidepressant) 10mg,

take one capsule by mouth daily.

Review on 7/29/25 and 8/7/25 of Client #2's
MARSs from February 22, 2025-July 29, 2025
revealed:

- No staff initials for administration for
Levonorgestrel-Ethiny! Estradiol on 4/1-4/22;

STATEMENT OF DEFICIENCIES x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A. BUILDING
8. WING
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

Division of Health Service Regulation
STATE FORM oe 4Kiltt if continuation sheet 7 of 14

Division of Health Service Regulation

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

V 118 Continued From page 6

= No staff initials for administration for
Benztropine Mesylate 1mg on 4/13, 4/16-4/20,

5/5, 5/6, 5/10, 5/11, 5/20, 5/22, 5/23, 5/25, 5/30,

6/9, 6/13;

2 No initials for administration for
Chlorpromazine

HCL 50mg on 4/6, 4/7, 4/10, 4/12, 4/13,

4/16-4/20, 5/5, 5/6, 5/10, 5/11, 5/20, 5/23, 5/25,
5/30, 6/9/, 6/13;

- No initials for administration for Guanfacine
ER

2mg on 4/13, 4/16-4/20, 5/5, 5/6, 5/10, 5/11, 5/20,
5/22, 5/23, 5/25, 5/30, 6/9, 6/13, 6/19;

- No initials for administration for Triamcinolone
0.1% cream on (7am) 4/16-4/22, 5/5, 5/29, 5/31,
6/14, 6/28; (7pm) 4/13, 4/17-4/20, 4/23, 4/24,

4/30, 5/5, 5/6, 5/11, 5/28, 6/9, 6/10, 6/12, 6/13,

6/17, 6/27, 6/28;

- No initials for administration for Lamotrigine
25mg on 4/16, 4/18, 4/19, 4/20, 4/22, 5/5;

- No initials for administration for Risperidone
2mg on 4/16, 4/18, 4/19, 4/20, 4/22, 5/5, 6/28; -

No initials for administration for Melatonin 5mg

on 4/3, 4/13, 4/16, 4/17, 4/18, 4/19, 4/20, 5/5,

5/6, 5/11,5/28, 6/9, 6/10, 6/12, 6/13, 6/23, 6/27,
6/28;

- No initials for administration for Prazosin HCL
2mg on 5/5, 5/6, 5/11, 5/28, 6/9, 6/10, 6/12, 6/13,
6/23, 6/27, 6/28;

- No initials for administration for Fluoxetine
HCL 10mg on 5/5, 6/28.

Interview on 7/30/25 with Client #1 revealed:
- Was administered her medications daily.

Interview on 7/30/25 with Client #2 revealed:
- Was administered her medications daily;- "I
don't know the name of the medications, | take too

many.”
Finding #2
Review on 7/31/25 of Staff #1's personnel record
revealed:
STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER

MHL013-240

Division of Health Service Regulation
STATE FORM

(X2) MULTIPLE CONSTRUCTION

A BUILDING

B. WING

e200

PRINTED: 08/22/2025
FORM APPROVED

PROVIDER'S PLAN OF CORRECTION 5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

(X3) DATE SURVEY
COMPLETED

08/11/2025

\f continuation sheet € of 14

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

NAME OF PROVIDER OR SUPPLIER.

STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

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

Continued From page 7

- Date of hire 1/7/25;
- No documentation for medication
administration training.

Interview on 7/30/25 with Staff #1 revealed: - The
QP was responsible for making sure the client's
medication was listed accurately on the MARs and
checked the MARs to ensure the staff initialed the
MARs after administration of medications;

- Signed the MARs when administered
medications to clients;

- Was trained by the facility's Human
Resources/Compliance Consultant in medication
administration when hired.

Review on 7/31/25 of Staff #2's personnel record
revealed:

- Date of hire 10/1/24;

- No documentation for medication
administration training.

Interview on 7/31/25 with Staff #2 revealed: -
“[QP] is responsible for making sure we signed
the MARs;”"

- Was trained by the facility's House
Manager/Associate Professional and former QP
in medication administration

- Administered medications to clients.

Review on 7/31/25 of Staff #3’s personnel record
revealed:

- Date of hire 2/26/25;

- No documentation for medication
administration training.

Interview on 7/31/25 with Staff #3 revealed: -The
House Manager/Associate Professional was
responsible for making sure staff signed off on
the MARs after administering medications;

CONCORD, NC 28027

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X41) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER.

MHLO013-240

A BUILDING

6. WING

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

08/11/2025

Division of Health Service Regulation
STATE FORM

4Ki14

If continuation sheet 9 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(XS)
COMPLETE

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION

(x4) ID

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

V 118 Continued From page 8

- Was trained by the House Manager/Associate
Professional in medication administration

Review on 8/7/25 of Staff #4's personnel record
revealed:

- Date of hire 11/25/24;

- No documentation for medication
administration training.

Attempted interview on 8/7/25 with Staff #4

revealed

: Attempted telephone call to Staff #4 but there
was no return call before exit of survey.

Review on 8/7/25 of Staff #5's personnel record
revealed:

- Date of hire 5/26/25;

- A certificate dated 6/2025, which reflected
Staff

#5 had received training in medication
administration from the facility's Human
Resources/Compliance Consultant.

Attempted interview on 8/7/25 with Staff #5

revealed:

- Attempted telephone call to Staff #5 but there
was no return call before exit of survey.

Review on 8/7/25 of Staff #6's personnel record
revealed:

- Date of hire 1/28/25;

- No documentation for medication
administration training.

Interview on 8/7/25 with Staff #6 revealed: -

The QP was responsible for the MARs and
medications;

- Was "trained" by the House
Manager/Associate Professional and QP in medication
administration.

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

MHL013-240 08/11/2025

Division of Health Service Regulation
STATE FORM be 4Ki11 If continuation sheet 10 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

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

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE EOMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Vv 118 Vv 118

Continued From page 9

Review on 7/31/25 of the QP's personnel record
revealed:

- Date of hire 3/15/25;

- Was trained in medication administration
on 5/4/22.

Interview on 7/31/25 with the QP revealed:

- Worked at the facility in the past and was
rehired the end of March 2025;

- Was responsible for the MARs and
medications;- Checked the MARs when the clients
were admitted and at the end of the month;

- “lam supposed to review the MARs
monthly, but | have not done that:"

- Was unable to provide an explanation for
why the MARs were not being checked monthly; -
"I'm going to start checking the MARs every few
days” to ensure medications were being signed off
on;

: Was retrained in medication
administration by the Human
Resources/Compliance Consultant when rehired.

Interview on 8/1/25 with the House
Manager/Associate Professional revealed: -

The QP was responsible for the medications

and MARs;

- Transferred medication administration
training from previous employer but was retrained
by the facility's Human Resources/Compliance
Consultant.

Interview on 8/5/25 with the Licensee revealed:

- The Human Resources/Compliance
Consultant

“handled all the trainings for the staff;"

- Was not aware that staff had to be trained
in medication administration by a registered nurse,
pharmacist or legally qualified person. Interview on
8/11/25 with the Human

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER, A. BUILDING COMPLETED

B WING
MHL013-240 08/11/2025

Division of Health Service Regulation
STATE FORM ome 4K If continuation sheet 11 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation

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

550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC

CONCORD, NC 28027
OH
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES: 1D 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 cal
DEFICIENCY)

eT

V 118 7 Vv 118
Continued From page 10

Resources/Compliance Consultant revealed: -
Contracted with Licensee for "close to a year now;"
- Was responsible for staff trainings.

- Assigned task for former employee to
ensure staff trainings were being completed;

- "| was in the process of completing an
audit on staff files and noticed trainings were not
completed;" - Contacted the pharmacist, who is
contracted to complete the medication
administration training with staff, and learned that
the trainings were scheduled but "it fell through the
cracks;”

- Scheduled medication administration
training for all staff for August 13, 2025.

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 8/11/25 of the facility's Plan of
Protection dated 8/11/25 and completed by the
Licensee revealed:
- "What immediate action will the facility take
to ensure the safety of the consumers in your care?
Transcending Heights LLC will ensure medication
requirements are followed per the rule 10A NCAC
27G .0209.
All staff will be trained per the rule, 'by a
registered nurse, pharmacist, or a legally qualified
person and privileged to prepare and administer
medications’.
In the context of healthcare, legally qualified
persons privileged to prepare and administer
medications generally include licensed medical
professionals, such as:
Physicians (MDs(Doctor of Medicine) and DOs
(Doctor of Osteopathic Medicine)): They have the
broadest prescriptive authority and can

[_ administer a wide range of medications.

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER ANBUILDING COMPLETED

8. WING
MHL013-240 08/11/2025

Division of Health Service Regulation
STATE FORM ‘oe 4KiI14 If continuation sheet 12 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

Vv 118 V 118
Continued From page 11

Registered Nurses (RNs): They are typically
responsible for administering medications
prescribed by a healthcare provider and often
oversee the administration by other personnel.

Licensed Practical Nurses (LPNs): They can also
administer medications under the supervision of a
registered nurse or doctor.

Physician Assistants (PAs): They can administer
medications in accordance with their approved
practice. under physician supervision.

Pharmacists: They verify prescriptions, dispense
medications, and may administer certain
medications like vaccines, depending on state
laws and collaborative practice agreements.
Advanced Practice Registered Nurses (APRNs):
This includes Nurse Practitioners (NPs), who
have advanced education and can prescribe and
administer medications.

- Describe your plans to make sure the
above happens.

Medication training will be scheduled with a
qualified person privileged to prepare and
administer medications on Wednesday, August 13,
2025."

Review on 8/11/25 of the revised facility's Plan of
Protection dated 8/11/25 and completed by the
Licensee revealed:

- "What immediate action will the facility take
to ensure the safety of the consumers in your care?
Only staff having current and up-to-date medication
certificates will administer medications. MAR's will
be checked daily for accuracy and to ensure that
the appropriately trained person has signed. Audit
will be conducted on staff files to ensure that
current employees are up to date on required
training. - Describe your plans to make sure the
above happens.

New and current staff will be trained and/or

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER, A BUNOING COMPLETED

5. WING
MHL013-240 08/11/2025

Division of Health Service Regulation
STATE FORM ove Kun if continuation sheet 13 of 14

PRINTED: 08/22/2025
FORM APPROVED

Division of Health Service Regulation
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

Vv 118 Continued From page 12 Vv 118

retrained to ensure medications are administered
correctly to residents in care.

MAR's will be checked daily to ensure medication
has been administered, and staff have
signed/initialed and documented properly per the
medication orders or discontinue orders.
Medication training will be scheduled with a
qualified person privileged to prepare and
administer medications on Wednesday, August 13,
2025."

The facility served children aged 13-17 years old
which included diagnoses Oppositional Defiant
Disorder, Attention Deficit Hyperactivity Disorder,
Post Traumatic Stress Disorder, Major
Depression, Generalized Anxiety Disorder and
Conduct Disorder. From February 22 to July 29,
2025 there were a total of 42 dates in which
medications were not documented as
administrated. Six paraprofessional staff
members who administered medications had not
received the required training by a registered
nurse, pharmacist, or other legally qualified
person, with the longest serving staff having
commenced employment in October 2024. The
Qualified Professional was responsible for
ensuring the MARs were current on a monthly
basis but failed to do so.

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

Steven Lanham ( EDT,

Division of Health Service Regulation
STATE FORM pene AKIN If continuation sheet 14 of 14

Signature: StH one L. petit

Email: faruqam31073@gmail.com
Title: CEO

inspection_type: MHLCS Annual

document_type: Plan of Correction


state: NC

facility_name: Transcending Heights  LLC

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

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:
Based on record review and interviews, the

facility failed toensure fire and disaster drills were
conducted quarterly and on each shift. The

Division of Health Service Regulation

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

STATE FORM

6808 4KINN1

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual survey was completed on 8/11/25.
Deficiencies were cited.
The facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 6 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.
V 114| 27G .0207 Emergency Plans and Supplies Vv 114

(X6) DATE

If continuation sheet 1 of 13

PRINTED: 08/22/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 1 Vv 114

findings are:

Review on 7/31/25 of the facility's fire and
disaster drill log from July 1, 2024-June 30, 2025
revealed:

3rd quarter (July- September 2024):

- No 1st shift (8am-3pm) disaster drills;

- No 3rd shift (11pm-8am) fire and disaster drills;
- No weekend (8am-8pm) shift fire and disaster
drills;

- No weekend (8pm-8am) shift fire and disaster
drills.

Ath quarter (October- December 2024):
- No 1st shift and 3rd shift fire and disaster drills;
- No weekend (8am-8pm) shift disaster drills.

1st quarter (January- March 2025):

- No 3rd shift fire and disaster drills;

- No weekend (8pm-8am) shift fire drills;

- No weekend (8am-8pm) shift disaster drills.

2nd quarter (April- June 2025):

- No 1st and 3rd shift fire and disaster drills;

- No 2nd shift (3pm-11pm) disaster drills;

- No weekend shift (8am-8pm) fire and disaster
drills;

- No weekend shift (8pm-8am) disaster drills.

Interview on 7/30/25 with Client #1 revealed:
- Denied completing fire and disaster drills since
admitted in facility May 2025.

Interview on 7/30/25 with Client #2 revealed:
- Denied completing fire and disaster drills;
- Denied knowing where to go if there was a fire.

Interview on 7/30/5 with Client #3 revealed:

- Denied fire and disaster drill since admitted in
July 2025.
Division of Health Service Regulation
STATE FORM

e899 AKIIN1 If continuation sheet 2 of 13

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

Interview on 7/30/25 with Staff #1 revealed:
- "No fire and disaster drills are being completed."

Interview on 7/31/25 with Staff #2 revealed:

- Completed fire and disaster drills;

- House Manager/Associate Professional and
staff on duty were responsible for completing the
drills;

- Completed a fire and disaster drill last month.

Interview on 7/31/25 with Staff #3 revealed:
- "I never done one (fire and disaster drill) since |
been there," February 2025.

Interview on 8/7/25 with Staff #6 revealed:

- Completed fire and disaster drills once a month;
- Participated in fire and disaster drills;

- Completed a fire and disaster drill last month.

Interview on 7/31/25 with the House
Manager/Associate Professional revealed:

- Was responsible for completing fire and disaster
drills;

- Was not completing fire and disaster drills;

- Planned to complete a fire and disaster drill on
7/31/25.

Interview on 7/29/25 with the Qualified
Professional revealed:

- There were several shifts (1st-8am-3pm, 2nd
3pm-11pm, 3rd 11pm-8am, weekend 8am-8pm
and 8pm-8am) in the facility;

- House Manager/Associate Professional was
responsible for fire and disaster drills;

- "We will start completing a drill every month."

Interview on 8/11/25 with the Human Resource
and Compliance Consultant revealed:
- House Manager/Associate Professional was

Division of Health Service Regulation

STATE FORM

6808 4KINN1

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 2 Vv 114

If continuation sheet 3 of 13

Division of Health Service Regulation

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

MHL013-240

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

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

PRINTED: 08/22/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

responsible for completing fire and disaster drills
or assigning various staff to complete the drills;

- Received fire and disaster drills on a spread
sheet after they are documented on an electronic
form.

V 118| 27G .0209 (C) Medication Requirements Vv 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 shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

C) instructions for administering the drug;

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

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

(
(
(
(

Division of Health Service Regulation
STATE FORM 009 AKII14

(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 3 Vv 114

If continuation sheet 4 of 13

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/22/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility failed to keep the MAR
current for 2 of 3 clients (#1, #2) and failed to
ensure 6 of 6 audited paraprofessional staff had
been trained in medication administration by a
registered nurse, pharmacist or other legally
qualified person and 1 of 1 Qualified Professional
(QP) failed to demonstrate competency. The
findings are:

Finding #1

Review on 7/31/25 of Client #1's record revealed:
- Admission date 5/2/25;

- Age 13 years old;

- Diagnoses Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder;

- Physician's order 3/9/25 Tri-Mili 28 (birth control)
tablet, take one tablet by mouth every day;
3/17/25 Topiramate (headaches) 100 mg
(milligram), take one tablet by mouth every day;
5/5/25 Aripiprazole (depression) 10mg, take one
tablet by mouth every day;

5/11/25 Denta 5000 Plus cream (fluoride
toothpaste), apply thin ribbon to toothbrush and
brush thoroughly once daily for 2 minutes
preferably at bedtime in place of regular
toothpaste;

7/9/25 Escitalopram (antidepressant) 5mg tablet,
take one tablet by mouth every day.

Review on 7/29/25 of Client #1's MARs from May
2, 2025-July 29, 2025 revealed:

- No staff initials for administration for

Division of Health Service Regulation
STATE FORM

6809

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 4 Vv 118

If continuation sheet 5 of 13

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

Escitalopram 5mg tablet; Tri-Mili 28 tablet on
5/29;

- No staff initials for administration for
Aripiprazole 10mg on 6/10, 6/13, 6/29;

- No staff initials for administration for Topiramate
100mg on 6/10, 6/13;

- Denta 5000 Plus cream was not listed on the
MAR for May and June.

Review on 7/31/25 of Client #2's record revealed:
- Admission date 2/9/25;

- Age 17 years old;

- Diagnoses Major Depressive Disorder, Post
Traumatic Stress Disorder (PTSD), Conduct
Disorder, Generalized Anxiety Disorder;

- Physician's Orders 2/10/25 Chlorpromazine
(antipsychotic) HCL (hydrochloride) 50mg, take
one tablet by mouth at bedtime; Guanfacine ER
(extended release) (nonstimulant) 2mg, take one
tablet by mouth at bedtime; Benztropine Mesylate
(muscle control) 1mg, take one tablet by mouth at
bedtime; Triamcinolone (dermatitis) 0.1% cream,
apply 1 application on the skin twice a day to
affected area; Risperidone (antipsychotic) 2mg,
take one tablet by mouth daily; Lamotrigine
(major depression) 25 mg, take two tablets by
mouth daily; Melatonin (sleep aid) 5mg, take one
tablet by mouth at bedtime;
Levonorgestrel-Ethinyl Estradiol (birth control)
0.2mg, take one tablet by mouth every day;
3/15/25 Prazosin HCL (PTSD) 2mg take one
capsule by mouth every night;

6/10/25 Fluoxetine HCL (antidepressant) 10mg,
take one capsule by mouth daily.

Review on 7/29/25 and 8/7/25 of Client #2's
MARs from February 22, 2025-July 29, 2025
revealed:

- No staff initials for administration for
Levonorgestrel-Ethinyl Estradiol on 4/1-4/22;

Division of Health Service Regulation

STATE FORM

6808 4KINN1

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 5 Vv 118

If continuation sheet 6 of 13

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

A. BUILDING:

550 ARCHDALE DRIVE
CONCORD, NC 28027

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

- No staff initials for administration for
Benztropine Mesylate 1mg on 4/13, 4/16-4/20,
5/5, 5/6, 5/10, 5/11, 5/20, 5/22, 5/23, 5/25, 5/30,
6/9, 6/13;

- No initials for administration for Chlorpromazine
HCL 50mg on 4/6, 4/7, 4/10, 4/12, 4/13,
4/16-4/20, 5/5, 5/6, 5/10, 5/11, 5/20, 5/23, 5/25,
5/30, 6/9/, 6/13;

- No initials for administration for Guanfacine ER
2mg on 4/13, 4/16-4/20, 5/5, 5/6, 5/10, 5/11, 5/20,
5/22, 5/23, 5/25, 5/30, 6/9, 6/13, 6/19;

- No initials for administration for Triamcinolone
0.1% cream on (7am) 4/16-4/22, 5/5, 5/29, 5/31,
6/14, 6/28; (7pm) 4/13, 4/17-4/20, 4/23, 4/24,
4/30, 5/5, 5/6, 5/11, 5/28, 6/9, 6/10, 6/12, 6/13,
6/17, 6/27, 6/28;

- No initials for administration for Lamotrigine
25mg on 4/16, 4/18, 4/19, 4/20, 4/22, 5/5;

- No initials for administration for Risperidone
2mg on 4/16, 4/18, 4/19, 4/20, 4/22, 5/5, 6/28;

- No initials for administration for Melatonin 5mg
on 4/3, 4/13, 4/16, 4/17, 4/18, 4/19, 4/20, 5/5, 5/6,
5/11,5/28, 6/9, 6/10, 6/12, 6/13, 6/23, 6/27, 6/28;
- No initials for administration for Prazosin HCL
2mg on 5/5, 5/6, 5/11, 5/28, 6/9, 6/10, 6/12, 6/13,
6/23, 6/27, 6/28;

- No initials for administration for Fluoxetine HCL
10mg on 5/5, 6/28.

Interview on 7/30/25 with Client #1 revealed:
- Was administered her medications daily.

Interview on 7/30/25 with Client #2 revealed:
- Was administered her medications daily;

- "| don't know the name of the medications, |
take too many."

Finding #2
Review on 7/31/25 of Staff #1's personnel record
revealed:

Division of Health Service Regulation
STATE FORM

6809

4KINN1

(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 Vv 118

If

continuation sheet 7 of 13

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118] Continued From page 7 Vv 118

- Date of hire 1/7/25;
- No documentation for medication administration
training.

Interview on 7/30/25 with Staff #1 revealed:

- The QP was responsible for making sure the
client's medication was listed accurately on the
MARs and checked the MARs to ensure the staff
initialed the MARs after administration of
medications;

- Signed the MARs when administered
medications to clients;

- Was trained by the facility's Human
Resources/Compliance Consultant in medication
administration when hired.

Review on 7/31/25 of Staff #2's personnel record
revealed:

- Date of hire 10/1/24;

- No documentation for medication administration
training.

Interview on 7/31/25 with Staff #2 revealed:

- "[QP] is responsible for making sure we signed
the MARs;"

- Was trained by the facility's House
Manager/Associate Professional and former QP
in medication administration

- Administered medications to clients.

Review on 7/31/25 of Staff #3's personnel record
revealed:

- Date of hire 2/26/25;

- No documentation for medication administration
training.

Interview on 7/31/25 with Staff #3 revealed:

-The House Manager/Associate Professional was
responsible for making sure staff signed off on
the MARs after administering medications;
Division of Health Service Regulation

STATE FORM 009 AKII14

If continuation sheet 8 of 13

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 08/22/2025

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

08/11/2025

- Was trained by the House Manager/Associate
Professional in medication administration.

Review on 8/7/25 of Staff #4's personnel record
revealed:

- Date of hire 11/25/24;

- No documentation for medication administration
training.

Attempted interview on 8/7/25 with Staff #4
revealed:

- Attempted telephone call to Staff #4 but there
was no return call before exit of survey.

Review on 8/7/25 of Staff #5's personnel record
revealed:

- Date of hire 5/26/25;

- Acertificate dated 6/2025 which reflected Staff
#5 had received training in medication
administration from the facility's Human
Resources/Compliance Consultant.

Attempted interview on 8/7/25 with Staff #5
revealed:

- Attempted telephone call to Staff #5 but there
was no return call before exit of survey.

Review on 8/7/25 of Staff #6's personnel record
revealed:

- Date of hire 1/28/25;

- No documentation for medication administration
training.

Interview on 8/7/25 with Staff #6 revealed:

- The QP was responsible for the MARs and
medications;

- Was "trained" by the House Manager/Associate
Professional and QP in medication
administration.

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 8 Vv 118

If continuation sheet 9 of 13

Division of Health Service Regulation

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

MHL013-240

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/22/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 9 Vv 118

Review on 7/31/25 of the QP's personnel record
revealed:

- Date of hire 3/15/25;

- Was trained in medication administration on
5/4/22.

Interview on 7/31/25 with the QP revealed:

- Worked at the facility in the past and rehired the
end of March 2025;

- Was responsible for the MARs and medications;
- Checked the MARs when the clients were
admitted and at the end of the month;

- "lam supposed to review the MARs monthly,
but | have not done that;"

- Was unable to provide an explanation for why
the MARs were not being checked monthly;

- "I'm going to start checking the MARs every few
days" to ensure medications were being signed
off on;

- Was retrained in medication administration by
the Human Resources/Compliance Consultant
when rehired.

Interview on 8/1/25 with the House
Manager/Associate Professional revealed:

- The QP was responsible for the medications
and MARs;

- Transferred medication administration training
from previous employer but was retrained by the
facility's Human Resources/Compliance
Consultant.

Interview on 8/5/25 with the Licensee revealed:

- The Human Resources/Compliance Consultant
“handled all the trainings for the staff;"

- Was not aware that staff had to be trained in
medication administration by a registered nurse,
pharmacist or legally qualified person.

Interview on 8/11/25 with the Human

Division of Health Service Regulation
STATE FORM

6809

4KINN1

If continuation sheet 10 of 13

Division of Health Service Regulation

PRINTED: 08/22/2025
FORM APPROVED

Resources/Compliance Consultant revealed:
-Contracted with Licensee for "close to a year
now;"

- Was responsible for staff trainings;

- Assigned task for former employee to ensure
staff trainings were being completed;

-" |was in process of completing an audit on staff
files and noticed trainings were not completed;"

- Contacted the pharmacist, who is contracted to
complete the medication administration training
with staff and learned that the trainings were
scheduled but "it fell through the cracks;"

- Scheduled medication administration training for
all staff for August 13, 2025.

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 8/11/25 of the facility's Plan of
Protection dated 8/11/25 and completed by the
Licensee revealed:

- "What immediate action will the facility take to
ensure the safety of the consumers in your care?
Transcending Heights LLC will ensure medication
requirements are followed per the rule 10A NCAC.
27G .0209.

All staff will be trained per the rule, 'by a
registered nurse, pharmacist, or a legally qualified
person and privileged to prepare and administer
medications’.

In the context of healthcare, legally qualified
persons privileged to prepare and administer
medications generally include licensed medical
professionals, such as:

Physicians (MDs(Doctor of Medicine) and DOs
(Doctor of Osteopathic Medicine)): They have the
broadest prescriptive authority and can
administer a wide range of medications.

Division of Health Service Regulation

STATE FORM

6808 4KINN1

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL013-240 08/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 10 Vv 118

If continuation sheet 11 of 13

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

NC 28027

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/22/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

Registered Nurses (RNs): They are typically
responsible for administering medications
prescribed by a healthcare provider and often
oversee the administration by other personnel.

Licensed Practical Nurses (LPNs): They can also
administer medications under the supervision of a
registered nurse or doctor.

Physician Assistants (PAs): They can administer
medications in accordance with their approved
practice, under physician supervision.

Pharmacists: They verify prescriptions, dispense
medications, and may administer certain
medications like vaccines, depending on state
laws and collaborative practice agreements.
Advanced Practice Registered Nurses (APRNs):
This includes Nurse Practitioners (NPs), who
have advanced education and can prescribe and
administer medications.

- Describe your plans to make sure the above
happens.

Medication training will be scheduled with a
qualified person privileged to prepare and
administer medications on Wednesday, August
13, 2025."

Review on 8/11/25 of the revised facility's Plan of
Protection dated 8/11/25 and completed by the
Licensee revealed:

- "What immediate action will the facility take to
ensure the safety of the consumers in your care?
Only staff having current and up-to-date
medication certificates will administer
medications. MAR's will be checked daily for
accuracy and to ensure that the appropriately
trained person has signed. Audit will be
conducted on staff files to ensure that current
employees are up to date on required training.

- Describe your plans to make sure the above
happens.

New and current staff will be trained and/or

Division of Health Service Regulation
STATE FORM

6809

4KINN1

(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 Vv 118

If continuation sheet 12 of 13

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

CONCORD,

NC 28027

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/22/2025

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/11/2025

retrained to ensure medications are administered
correctly to residents in care.

MAR's will be checked daily to ensure medication
has been administered, and staff have
signed/initialed and documented properly per the
medication orders or discontinue orders.
Medication training will be scheduled with a
qualified person privileged to prepare and
administer medications on Wednesday, August
13, 2025."

The facility served children aged 13-17 years old
which included diagnoses Oppositional Defiant
Disorder, Attention Deficit Hyperactivity Disorder,
Post Traumatic Stress Disorder, Major
Depression, Generalized Anxiety Disorder and
Conduct Disorder. From February 22 to July 29,
2025 there were a total of 42 dates in which
medications were not documented as
administrated. Six paraprofessional staff
members who administered medications had not
received the required training by a registered
nurse, pharmacist, or other legally qualified
person, with the longest serving staff having
commenced employment in October 2024. The
Qualified Professional was responsible for
ensuring the MARs were current on a monthly
basis but failed to do so.

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

Division of Health Service Regulation
STATE FORM

6809

4KINN1

(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 Vv 118

If continuation sheet 13 of 13

document_type: Statement of Deficiency