facility_name: Georgie's Helping Hand

summary: Statement of Deficency - MHLCS Annual and Follow-up

raw_content:
Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

ROAD

TAYLORSVILLE, NC 28681

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

PRINTED: 06/03/2025

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
06/04/2025

(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 000) INITIAL COMMENTS Vv 000

An annual and follow up survey was attempted on
June 4, 2025. According to the Director, there are
no clients being served at the facility. The last
time clients were served at the facility was August
2, 2024.

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

Observation on 6/3/25 at approximately 12:15 pm
revealed:

-Two men were present at the facility on the front
porch and identified themselves as maintenance
men.

-Several machine tools, including an electric skill
saw, was on the front porch.

Review on 6/3/25 of Former Client #1's record
revealed:

-Age: 17

-Date of Admission: 4/30/24

-Date of Discharge: 8/2/24

-Diagnosis: Unspecified Psychosis

Interview on 6/3/25 with the Director revealed:
-The facility was not currently serving clients.
-The last client served was in August of 2024.
-Was currently in the process of making repairs to
the facility.

-Was "...currently in the process of accepting
referrals and screening prospective clients for
admission..."

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

STATE FORM

6899

$Z1U11

TITLE

(X6) DATE

If continuation sheet 1 of 1

document_type: Statement of Deficency


state: NC

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 03/04/2024

(X2) MULTIPLE CONSTRUCTION

FORM APPROVED

(X3) DATE SURVEY

A limited follow up survey for the Type B was
completed on 2/28/24. This was a limited follow
up survey, only 10A NCAC 27G.1701 (V293) with
cross references 10A NCAC 27G.1702 (V294),
10A NCAC 27G.1704 (V296), 10A NCAC
27G.1705 (V297) and 10A NCAC 27G.1706
(V298) were reviewed for compliance. The
following were brought back into compliance 10A
NCAC 27G.1701 (V293) with cross references
10A NCAC 27G.1702 (V294), 10A NCAC
27G.1704 (V296), 10A NCAC 27G.1705 (V297)
and 10A NCAC 27G.1706 (V298). No deficiencies
were cited.

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

This facility is licensed for 5 and currently has a
census of 1. The survey sample consisted of
audits of 1 current client.

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

STATE FORM

TITLE

6808 X40H11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL002-032 02/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
TAYLORSVILLE, NC 28681
(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 Vv 000

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


facility_name: Cornerstone Treatment Facility

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

raw_content:
PRINTED: 02/26/2026
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

c
MHL004-016 B. WING _____ 02/13/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
WADESBORO, NC 28170

(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)

CORNERSTONE TREATMENT FACILITY

V 000} INITIAL COMMENTS Vv 000

Acomplaint and follow up survey was completed
on February 13, 2026. The complaints were
substantiated (Intake #NC00235638 and
#NC00235659). A deficiency was cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1900 PRTF
Psychiatric Residential Treatment Facility for
children and adolescents.

The facility is licensed for twelve and has a
current census of eight. The survey sample
consisted of audits of three current clients and
three former clients.

V 112] 27G .0205 (C-D) v 112
Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

(6) written consent or agreement by the client or
responsible party, or a written statement by the

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

STATE FORM 6899 LQGU11 If continuation sheet 1 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY 129 WALLCE ROAD

WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

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

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

V 112] Continued From page 1 Vv 112

provider stating why such consent could not be
obtained.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
acility failed to develop and implement goals and
strategies to address the needs of one of three
audited clients (client #1) and three of three
ormer clients (former client #4, former client #5
and former client #6). The findings are:

Review on 1/29/26 of client #1's record revealed:
-Admission date of 11/24/25.

-Diagnoses of Attention Deficit Hyperactivity
Disorder (ADHD), Major Depressive Disorder,
Disruptive Mood Dysregulation Disorder,
Oppositional Defiant Disorder and Post Traumatic
Stress Disorder.

-16 years old.

-A comprehensive clinical assessment (CCA)
dated 12/01/25-" ... The client has a significant
history of eloping, usually at night, and would
return before sunrise. She was caught leaving
with an unidentified male on various occasions.
The client reported that she was only leaving to
get something to eat."

-The Person-Centered Plan (PCP) was dated
1/14/26.

-The PCP had no goals or strategies to address
elopement.

Division of Health Service Regulation

STATE FORM 6899 LQGU11 If continuation sheet 2 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

Review on 1/29/26 of former client #4's record
revealed:

-Admission date of 10/20/25.

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions, Generalized Anxiety
Disorder and ADHD.

-13 years old.

-Discharge date was 1/22/26.

-A CCA dated 10/24/25 -" ...Records from 7/2025
note the client eloped from placement on 6/10/25
with a male peer, age 14, with previous client
disclosure of engaging in sexual intercourse
between them during the elopement. The client
was found weeks later staying with another older
male whom she had met before, but did not
remember where. That man contacted the police
to pick up the client ..."

-The PCP dated 12/16/25.

-The PCP had no goals or strategies to address
elopement.

Review on 1/29/26 of former client #5's record
revealed:

-Admission date of 1/5/26.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Conduct Disorder, Generalized Anxiety
Disorder, Post Traumatic Stress Disorder and
ADHD.

-Discharge date was 1/22/26.

-17 years old.

-A comprehensive clinical assessment dated
1/9/26-" ...history of gang involvement, loss/grief,
verbal/physical aggression, oppositional,
manipulation, deception, self-destructive
behavior, lying, depression/anxiety, stealing
(motor vehicle theft), elopement and absent
without official leave (AWOL)."

-The PCP dated 12/15/25 was accepted and
reviewed as an appropriate plan.

-The PCP had no goals or strategies to address
Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 2 Vv 112

If continuation sheet 3 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

elopement.

Review on 1/29/26 of former client #6's record
revealed:

-Admission date of 10/20/25.

-Diagnoses of ADHD, Oppositional Defiant
Disorder, Generalized Anxiety Disorder, Major
Depressive Disorder and Post Traumatic Stress
Disorder.

-17 years old.

-Discharge date was 1/22/26.

-A comprehensive clinical assessment (CCA)
dated 10/24/25 -" ...Was in a level 3 group home
and awaiting placement in a Psychiatric
Residential Treatment Facility; history of assault,
running away (8 times in the past year), anxiety,
property destruction and substance use (alcohol
and marijuana); had numerous placements,
eloped from Department of Social Service office."
-The PCP was dated 12/5/25.

-The PCP had no goals or strategies to address
elopement.

Review on 1/30/26 and 2/5/26 of the North
Carolina Incident Response Improvement System
(IRIS) from November 1, 2025 thru January 19,
2026 revealed:

-Client #1 eloped from the facility on 1/19/26.
-Former client #4 eloped from the facility on
12/4/25 and 1/19/26.

-Former client #5 eloped from the facility on
1/19/26.

-Former client #6 eloped from the facility on
11/23/25, 11/24/25, 12/4/25 and 1/5/26.

Interview on 1/30/26 with client #1 revealed:
-She eloped from her previous placement to get
some food.

-"| mean | came back. Before that | was in foster
care and ran away there too."

Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 3 Vv 112

If continuation sheet 4 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

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)

Vv 112 Vv 112

Continued From page 4

-They (former client #4 and former client #5)
planned to leave the facility.

-She was not sure of the specific date as former
client #4 was the coordinator with the adult male.
-She went to her room, put on her shoes and one
of the other clients kicked open the door on the
unit on 1/19/26.

-"| was in the back, | don't know who kicked the
door. | did close it and kept running."

-She was taken to a family member house eighty
miles away from the facility.

Interview on 2/6/26 with former client #4 revealed:
The adult male she considered to be like a "father
figure".

-She ran away from a previous placement and
connected with the adult male in the community.
-"You could pop the door lock to the nurse office."
-"Can bust it down with your hip or kick it. Since |
been there door been easy to open."

-Another client had previously kicked the unit
door and left the facility.

-"We ran and kicked the door and went through
it”

-"The white door by the front door was unlocked
and the main door always open."

-"She took the cordless phone from the nurses
station."

-"| took the phone to the bathroom, made the call
(to the adult male) and returned the phone back
to the nurses station."

-"Staff were around not paying attention."

-"We had been planning to leave for about a
week."

-On 1/19/26 client #1, former client #4 and former
client #5 all walked down the hall at different
times to get their shoes.

-Staff #3 was on the hall, staff #1 and former staff
#5 were in the common area and staff #2 was in
the kitchen.

Division of Health Service Regulation

STATE FORM

6899 LQGU11

If continuation sheet 5 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

-"Somebody said comeback, someone got in their
cars- [staff #2] and somebody, | don't remember."
-"Took us almost 2 hours to get to the waiting
spot. We kept having to hide from staff and the
police."

-"The adult male was already waiting for us in the
meeting spot, the neighborhood."

-"We told him to wait and drive around the
neighborhood until we contacted him."

-She went to a stranger in the neighborhood and
asked to use their phone.

-"He (adult male) was only a few houses away in
the neighborhood."

-The adult male took everyone to their
destinations.

-Client #1 went to be with her family in town
approximately 80 miles away.

-Former client #5 went to be with her family in
lown approximately 42 miles away.
-"| was found with the adult male whil
station two days later."

-"| was staying with him (adult male) at his home
located 31 miles away from the facility."

-"The officer noticed me in the car. We were on
he way to see [former client #5]."
-Her goal is to be in foster care or group home.

- "| have been at previous placements and gonna
refuse being in placements because | don't want
io be there. | want to be with him."

le at the gas

nterview on 2/3/26 with former client #5 revealed:
-"We [client #1 and former client #4] planned to
leave the facility."

-"[Former client #4] knew the adult male that
picked us up in the community."

-"We just busted through the door on the unit.
The front door is always open."

-A former client broke the door on the unit when
she ran away on 12/4/25.

-"We took off running and didn't look back."
Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 5 Vv 112

If continuation sheet 6 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

-"He picked us up in the ‘hood’, across the
highway from [store with yellow sign]."

-"He dropped me off at my father's home in [city]
one hour away."

-The father's home was forty-two miles away from
the facility.

-"The adult male that had [former client #4] told
on us and told where he took me and [client #1]."

Interviews with former client #6 were
unsuccessful.

-Attempted phone calls with former client #6 legal
guardian on 2/4/25, 2/5/26 and 2/6/26.

-Unable to leave a message as mailbox was full.

Interview on 1/30/26 with staff #1 revealed:

-The incident took place around 6:45pm on
1/19/26.

-She and former staff #5 were in the common
area with the clients on.

-Staff #2 was in the kitchen unclogging the sink,
staff #3 was sitting in the hallway monitoring client
#2 who had went to bed and staff #4 had stepped
off the unit to get something from her car.

-"The clients were acting different- watching the
moves of staff and getting the clients to ask
questions."

-"[Client #1], [former client #4] and [former client
#5] started to complain their stomach hurt and
needed to use the bathroom, one by one but they
snuck on the hall, put on their jackets. [Client #1]
had a cheetah print blanket wrapped around her
shoulders."

-The clients asked her something and she looked
up "they (client #1, former client #4 and former
client #5) all locked arms and kicked the door on
the unit and took off running."

-She was unaware that clients did not have goals
or strategies to address elopement.

Division of Health Service Regulation

STATE FORM 6899

LQGU11

(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 112| Continued From page 6 Vv 112

If continuation sheet 7 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

Interview on 1/30/26 with staff #2 revealed:

-He was in the kitchen unclogging the drain on
1/19/26, the day of the incident.

-Clients had just had dinner.

-Client #1, former client #4 and former client #5
stated they were not hungry, disliked the
prepared meal and declined their alternative
option for dinner.

-He heard the "boom" and came to the kitchen
door and staff #1 informed him of the elopement
of the three clients (client #1, former client #4 and
former client #5).

-"| immediately ran out and got in my car to start
searching. | went through neighborhoods, ran
through the puddles in the cold. | kept looking
until 4:15am."

-Other staff came in to help search for the clients
that evening as well.

-She was unaware that clients did not have goals
or strategies to address elopement.

Interview on 2/5/26 with staff #3 revealed:

-She was sitting in the hallway by the bedroom of
client #2 who had went to bed early on 1/19/26.
-She heard a "boom" and saw client #1, former
client #4 and former client #5 kicked open the
door on the unit and running down the hallway to
the front door.

-She was unaware that clients did not have goals
or strategies to address elopement.

Interview on 2/6/26 with staff #4 revealed:

-"Prior to the day of the incident, they wanted me
to get them the phone from the nurse office and |
told them no." They then said we are gonna try to
take the phone and distract the nurse and take it
to make a call."

-"| hid the phone in the staff cubby area in the
hallway."

-She informed the House Manager, staff #1 and
Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 7 Vv 112

If continuation sheet 8 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

staff #2 the later part of the week/into the
weekend before they eloped from the facility of
their trying to access the phone to call this guy
and leave the facility.

-The House Manager, staff #1 or staff #2
provided no response to being informed about the
girls (clients) plan to leave the facility.

-"The girls (clients) were plotting all day; kept
saying they can't wait to get out of here."

-On 1/19/26, the date of the incident, she had
made dinner and the sink was clogged and
requested help to unclog the sink.

-Staff #2 went into the kitchen to assist with
unclogging the kitchen sink.

-She went outside to her car to get a soda from
her trunk.

-The drink was in a can, so she was not allowed
to bring the drink on the unit, so she stood in the
doorway of the House Manager office and drank
the soda.

-"| heard three booms like someone was kicking
the doors."

-"| was told the girls (clients) had a running start
from the hallway and kicked through the doors.
-"[House Manager] and | yelled for them to
comeback, but they kept going. | went and got
my car keys and jumped in my car to go
searching."

-She along with the House Manager and staff #2
all searched for the clients in their cars.

-She was not aware of the clients not having
goals or strategies to address elopement.

Interview with former staff #6 was unsuccessful.
-Attempted phone calls were made on 1/30/26,
2/4/26, 2/5/26 and 2/6/26.

-Voicemail was not set up and unable to leave a
message.

-Requested assistance from the House Manager
and the Executive Director on 1/30/26 to make
Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 8 Vv 112

If continuation sheet 9 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

contact.

-Both the House Manager and the Executive
Director stated they called and she did not
respond to their calls.

Interview on 2/5/26 with the House Manager
revealed:

-She was not in the building when the 1/19/26
elopement incident occurred.

-She was getting off work and heading to her car.
-"| grabbed arm of [client #1] as she was going by
but she jerked away and kept going."

-She returned back in the building and contacted
the Executive Director and then called the police.
-"The door on the unit remained locked. The
glass door and the door to enter the office area
are always unlocked. The door to the conference
room, door to exit the conference room and the
exit door on the hallway is locked as well."

-"This is the longest clients have been away from
he facility. Normally we are able to locate them."

nterview on 2/13/26 with the Director of
Operations revealed:

-The facility was staff secure and not a locked
acility.

-The main entrance door and door entering the
administrative offices are not locked.

-The exit door on the hall with the client
bedrooms, kitchen, conference room, door
leaving the conference room and door to the unit
are locked.

-Staff are to contact the House Manager, the
House Manager notifies the Executive Director
and the Executive Director notifies him.

-He was made aware of all elopements that occur
at the facility.

-He acknowledged client #1, former client #4,
ormer client #5 and former client #6 plans did not
have strategies to address elopement.

Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 9 Vv 112

If continuation sheet 10 of 12

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

Review on 2/13/26 of the Plan of Protection
written by the Chief Executive Officer dated
2/13/26 revealed: "What immediate action will
the facility take to ensure the safety of the
consumers in your care? 1. Upon initial review of
incoming admission documentation both he
clinician and care manager will access all prior Tx
(treatment) goals and address pertinent concerns
such as elopement during the Intake and
development of PCP and clinical goals. 2. All
goals will be reviewed at the initial Child and
Family Team meeting (PCP Goals) with the Tx
team. Clinical will review all therapy goals of new
admissions during the monthly Clinical Team
meeting and address prior, existing and new Tx
goal concerns. Describe your plans to make sure
the above happens. Care management and
Clinical will revise current documentation to
capture prior existing and new treatment goal
concerns upon admission and ongoing with
monthly reviews at the CFT meetings. This will
include both clinical and PCP Tx goals. All
documentation will be reviewed and updated over
the next 45 days by the c/s next CFT review
date."

Clients at the facility had diagnoses of Adjustment
Disorder with Mixed Disturbance of Emotions,
Attention Deficit Hyperactivity Disorder, Disruptive
Mood Dysregulation Disorder, Generalized
Anxiety Disorder, Oppositional Defiant Disorder
and Post Traumatic Stress Disorder. Client #1,
former client #4, former client #5 and former
client #6 all had history of elopement. There
were no goals and strategies in any of their PCP's
addressing the elopement. Former client #4
eloped from a previous placement with the
26-year-old. Former client #4 and former client
#6 eloped together on 12/4/25. Client #1, former
Division of Health Service Regulation

STATE FORM

6899 LQGU11

(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 112| Continued From page 10 Vv 112

If continuation sheet 11 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL004-016

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

PRINTED: 02/26/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/13/2026

client #4 and former client #5 all eloped together
on 1/19/26. The local police located former client
#4 on 1/21/26 thirty-one miles away from the
facility. Once taken into custody the adult male
shared the locations of client #1 and former client
#5. Client #1 was located on 1/22/26 eighty miles
away from the facility and former client #5 was
located on 1/21/26 forty-two miles from the
facility.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

Division of Health Service Regulation
STATE FORM

6899

(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 112| Continued From page 11 Vv 112

LQGU11

If continuation sheet 12 of 12

inspection_type: MHLCS Complaint and Follow-up


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

raw_content:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHL004-016
NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

SUMMARY STATEMENT OF DEFICIENCIES

1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

8. WING

(X2) MULTIPLE CONSTRUCTION
A BUILDING.

:
]

PRINTED: 02/26/2026

FORM APPROVED

(%3) DATE SURVEY
COMPLETED

Cc
02/13/2026

STREET ADDRESS. CITY, STATE, ZIP CODE
129 WALLCE ROAD
WADESBORG, NC 28170

{EACH DEFICIENCY MUST 8E PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

V 000) INITIAL COMMENTS

Acomplaint and follow up survey was completed
on February 13, 2026. The complaints were

substantiated (Intake #NC00235638 and
#NC00235659). A deficiency was cited.

The facility is licensed for the following service

category: 10ANCAC 27G .1900 PRTF

Psychiatric Residential Treatment Facility for

children and adolescents.

The facility is licensed for twelve and has a
current census of eight. The survey sample
consisted of audits of three current clients and

three former clients.

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

410A NCAG 27G .0205

ASSESSMENT AND

TREATMENT/HABILITATION OR SERVICE

PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or

legally responsible person or both, within

30 days .

of admission for clients who are expected to

receive services beyond 30 days.
| (d) The plan shall include:

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

projected date of achievement;
(2) strategies;
(3) staff responsible;

(4) a schedule for review of the plan at least

annually in consultation with the client or
responsible person or both;

legally

(8) basis for evaluation or assessment of

outcome achievement; and

(6) written consent or agreement by the client or

responsible party, or a written statement
Division of Health Service Regulation

by the

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

lr, oF

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

Upon initial review of incoming admission
documentation, the ctinician and care manager
will assess all prior treatment goals and identify
any pertinent concerns during the client’s intake.
Based on this review, the team will develop the
Person-Centered Plan (PCP) and corresponding
Clinical goals. All treatment goals will be
reviewed at the initial Child and Family Team
(CFT) meeting with the fult interdisciplinary
team. Additionally, the clinical team will review

| therapy goals for all new admissions during

monthly clinical team meetings to address prior,
existing, and newly identified treatment goal

| concems.

| The clinician and care manager will use a

standardized intake checklist to document
review of prior treatment goals and development
of the PCP and clinical goals at admission. All
goals will be reviewed during the initial CFT
meeting and documented in meeting notes. New
admissions will be reviewed during monthly
clinical team meetings to ensure prior, existing,
and new treatment goals are addressed. The
Clinical Director (or designee) will conduct
periodic chart audits to monitor compliance and
address any deficiencies through supervision
_and corrective action asneeded.

TITLE (X6} DATE

MAR 2.3 2026
DHSR-MH Licensure Sect

fcontinuation sheet 1 of 12

PRINTED: 02/26/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (<2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING:

MHL004-016 8. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
CORNERSTONE TREATMENT FACILITY

129 WALLCE ROAD

WADESBORO, NC 28170

(x4) (0 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX {EACH DEFICIENCY MUST 8E PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE Dare

DEFICIENCY)

V 112] Continued From page 1

provider stating why such consent could not be
obtained.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facitity failed to develop and implement goals and
strategies to address the needs of one of three
audited clients (client #1) and three of three
former clients (former client #4, former client #5 |
and former client #8). The findings are: |

Review on 1/29/26 of client #1's record revealed:
-Admission date of 11/24/25.

-Diagnoses of Attention Deficit Hyperactivity
Disorder (ADHD), Major Depressive Disorder,
Disruptive Mood Dysregulation Disorder,
Oppositional Defiant Disorder and Post Traumatic
Stress Disorder.

+16 years old.

-A comprehensive clinical assessment (CCA)
dated 12/01/25-" ... The client has a significant
history of eloping, usually at night, and would
return before sunrise. She was caught leaving
with an unidentified male on various occasions.
The client reported that she was only leaving to
get something to eat.”

-The Person-Centered Plan (PCP) was dated
1/44/26,

-The PCP had no goals or strategies to address
elopement.

Olvision of Health Service Regulation
STATE FORM Li LaGuti lt continuation sheet 2 of 12

STATEM ’ {X2) MULTIPLE CONSTRUCTION
A BUILDING:

AND PLAN OF CORRECTION (DENTIFICATION NUMBER:

MHL.004-016 8. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD

NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

PRINTED: 02/26/2026
FORM APPROVED

(%3) DATE SURVEY
COMPLETED

c
02/13/2026

WADESBORO, NC 28170

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

Continued From page 2

Review on 1/29/26 of former client #4’s record
revealed:

-Admission date of 10/20/25.

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions, Generalized Anxiety
Disorder and ADHD.

+13 years old.

~Discharge date was 1/22/26.

-ACCA dated 10/24/25 -" ...Records from 7/2025
note the client eloped from placement on 6/10/25 |
with a male peer, age 14, with previous client i
disclosure of engaging in sexual intercourse
between them during the elopement. The client
was found weeks later staying with another older
mate whom she had met before, but did not
remember where, That man contacted the police |
to pick up the client ..."

-The PCP dated 12/16/25.

-The PCP had no goals or strategies to address
elopement.

Review on 1/29/26 of former client #5's record
revealed:

-Admission date of 1/5/26.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Conduct Disorder, Generalized Anxiety
Disorder, Post Traumatic Stress Disorder and
ADHD.

-Discharge date was 1/22/26.

-17 years old.

-A comprehensive clinical assessment dated |
1/9/26-" ...history of gang involvement, loss/grief,
verbal/physical aggression, oppositional,
manipulation, deception, self-destructive

behavior, lying, depression/anxiety, stealing
(moter vehicle theft), elopement and absent
without official leave (AWOL)." :
-The PCP dated 12/15/25 was accepted and |

teviewed as an appropriate plan.
-The PCP had no goals or strategies to address

Diviston of Health Service Regulation
STATE FORM anes

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

LaGuii Wcontinuation sheat Sof 12

PRINTED: 02/26/2026
FORM APPROVED

STATEMENT OF OEFICIENCIES (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER: Acces COMPLETED

Cc
MHL004-016 B. WING 02/13/2026

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

129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

0@) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFVING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

V 112] Continued From page 3
elopement.

Review on 1/29/26 of former client #6's record
revealed:

-Admission date of 10/20/25,

-Diagnoses of ADHD, Oppositional Defiant
Disorder, Generalized Anxiety Disorder, Major
Depressive Disorder and Post Traumatic Stress
Disorder.

-17 years old.

-Discharge date was 1/22/26.

-A comprehensive clinical assessment (CCA)
dated 10/24/25 -" ...Was in a level 3 group home |
and awaiting placement in a Psychiatric
Residential Treatment Facility; history of assault, |
running away (8 times in the past year), anxiety, |
property destruction and substance use (alcoho
and marijuana); had numerous placements,
eloped from Department of Sacial Service office.”
-The PCP was dated 12/5/25.

-The PCP had no goals or strategies to address
elopement.

Review on 1/30/26 and 2/5/26 of the North
Carolina Incident Response Improvement System
(IRIS) from November 1, 2025 thru January 19,
2026 revealed:

-Client #1 eloped from the facility on 1/19/26.
-Former client #4 eloped from the facility on
12/4/25 and 1/19/26.

-Former client #5 efoped from the facility on
1/19/26.

-Former client #6 efoped from the facility on
11/23/25, 11/24/25, 12/4/25 and 1/5/26.

Interview on 1/30/26 with client #1 revealed:
-She eloped from her previous placement to get
some food.
-"| mean | came back. Before that | was in foster
care and ran away there too."
Division of Health Service Regulation
STATE FORM Ld Lacuit Wf continuation sheet 4 of 12

PRINTED: 02/26/2026
FORM APPROVED

STATEMENT OF DEFICIENCI (Xt) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFIGATION NUMBER: A. BUILDING: COMPLETED

c
MHL004-016 8. WING 02/13/2026

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

GORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

Continued From page 4

-They (former client #4 and former client #5)
planned to leave the facility.

-She was not sure of the specific date as former
client #4 was the coordinator with the adult male.
-She went to her room, put on her shoes and one
of the other clients kicked open the door on the
unit on 1/19/26,

-| was in the back, | don't know who kicked the
door. | did close it and kept running."

-She was taken to a family member house eighty
miles away from the facility.

Interview on 2/6/26 with former client #4 revealed:
The adult male she considered to be like a "father
figure".

-She ran away from a previous placement and
connected with the adult male in the community.
~"You could pop the door lock to the nurse office.”
-"Can bust it down with your hip or kick it. Since |
been there door been easy to open."

-Another client had previously kicked the unit

door and left the facility.

-"We ran and kicked the door and went through
-"The white door by the front door was unlocked
and the main door always open.”

-"She took the cordless phone from the nurses
station."

«"L took the phone to the bathroom, made the call
(to the adult male) and returned the phone back

to the nurses station.”

-"Staff were around not paying attention.”

-"We had been planning to leave for about a
week.”

-On 1/19/26 client #1, former client #4 and former :
client #5 all walked down the hall at different i
times to get their shoes.

-Staff #3 was on the hall, staff #1 and former staff
#5 were in the common area and staff #2 was in
the kitchen.

Dnision of Healin Service Regulation

STATE FORM badd LaGui1 continuation sheet 5 of 12

on of Health Service Regulation

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

MHL004-016
NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

PRINTED: 02/26/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc

aed 02/13/2026

STREET ADDRESS. CITY, STATE, ZIP CODE
129 WALLCE ROAD

WADESBORO, NC 28170

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

V 112] Continued From page 5

-"Somebody said comeback, someone got in their
cars- [staff #2] and somebody, | don't remember.”
-"Took us almost 2 hours to get to the waiting
spot. We kept having to hide from staff and the
police.”

-"The adult male was already waiting for us in the
meeting spot, the neighborhood."

-"We told him to wait and drive around the
neighborhood until we contacted him.”

-She went to a stranger in the neighborhood and
asked to use their phone.

-"He (adult male) was only a few houses away in
the neighborhoad."

-The adult male took everyone to their
destinations.

-Client #1 went to be with her family in town
approximately 80 miles away.

-Former client #5 went to be with her family in
town approximately 42 miles away.

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULO 8E
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY}

‘vit

-"| was found with the adult male while at the gas

station two days later."

-"| was staying with him (adult male) at his home

located 31 miles away from the facility."

-"The officer noticed me in the car. We were on
the way to see {former client #5]."

~-Her goal is to be in foster care or group home.
-“l have been at previous placements and gonna

|

tefuse being in placements because ¢ don't want j

to be there. | want to be with him."

Interview on 2/3/26 with former client #5 revealed:
"We [client #1 and former client #4) planned to
leave the facility."
="[Former client #4] knew the adult male that
picked us up in the community.”
-"We just busted through the door on the unit.
The front door is always open."
-A former client broke the door on the unit when
she ran away on 12/4/25.
-"We took off running and didn't look back."
Oivision of Health Service Regula
STATE FORM

{continuation sheet 6 of 12

Lacuit

PRINTED: 02/26/2026
FORM APPROVED

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

c
MHL004-016 8. WING 02/43/2026

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

129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

V 112! Continued From page 6

~"He picked us up in the ‘hood’, across the
highway from {store with yellow sign].”

-"He dropped me off at my father’s home in [city]
one hour away."

-The father's home was forty-two miles away from
the facility.

~The adult male that had [former client #4] told
on us and told where he took me and [client #1].

Interviews with former client #6 were
unsuccessful.

-Attempted phone calls with former client #6 legal
guardian on 2/4/25, 2/8/26 and 2/6/26.

-Unable to leave a message as mailbox was full.

Interview on 1/30/26 with staff #1 revealed:

-The incident took place around 6:45pm on
1/19/26.

-She and former staff #5 were in the common

area with the clients on.

-Staff #2 was in the kitchen unclogging the sink,
staff #3 was sitting in the hallway monitoring client
#2 who had went to bed and staff #4 had stepped
off the unit to get something from her car.

~The clients were acting different- watching the
moves of staff and getting the clients to ask
questions."

-"[Client #1], (former client #4] and [former client
#5) started to complain their stomach hurt and
needed to use the bathroom, one by one but they
snuck on the hall, put on their jackets. [Client #1)
had a cheetah print blanket wrapped around her
shoulders. |
The clients asked her something and she looked ;
up “they (client #1, former client #4 and former
client #5) all locked arms and kicked the dooron ©
the unit and took off running.”

-She was unaware that clients did not have goals
or strategies to address elopement.

STATE FORM an Lacui (continuation sheet 7 of 12

PRINTED: 02/26/2026
FORM APPROVED

5 equlatio
STATEMENT OF DEFICIENCIES: (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED

Cc
MHL004-016 8. WING ______ 02/13/2026

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

129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (XS)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENGED TO THE APPROPRIATE. DATE
DEFICIENCY)

Continued From page 7

Interview on 1/30/26 with staff #2 revealed:

-He was in the kitchen unclogging the drain on
1/19/26, the day of the incident.

-Clients had just had dinner.

-Client #1, former client #4 and former client #5
stated they were not hungry, disliked the
prepared meal and declined their alternative
option for dinner.

-He heard the "boom" and came to the kitchen
door and staff #1 informed him of the elopement
of the three clients (client #1, former client #4 and
former client #5).

-"| immediately ran out and got in my car to start
searching. | went through neighborhoods, ran
through the puddles in the cold. | kept looking
until 4:15am."

-Other staff came in to help search for the clients
that evening as well,

-She was unaware that clients did not have goals
or strategies to address elopement. |

Interview on 2/5/26 with staff #3 revealed:

-She was sifting in the hallway by the bedroom of
client #2 who had went to bed early on 1/19/26.
-She heard a “boom" and saw client #1, former
client #4 and former client #5 kicked open the
door on the unit and running down the hallway to |
the front door.

-She was unaware that clients did not have goals
or strategies to address elopement.

Interview on 2/6/26 with staff #4 revealed:
~Prior to the day of the incident, they wanted me
to get them the phone from the nurse office and | |
told them no.” They then said we are gonna try to
take the phone and distract the nurse and take it
to make a call.”
-"l hid the phone in the staff cubby area in the
hallway.”
-She informed the House Manager, staff #1 and
Division of Health Service Regulation
STATE FORM eto Laguti {continuation sheet 6 of 12

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

‘K1) PROVIDERISUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL004-016
NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

PRINTED: 02/26/2026
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILOING:

3) DATE SURVEY
COMPLETED

Cc

Cotes 02/13/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD

WADESBORO, NC 28170

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

Continued From page 8

staff #2 the tater part of the week/into the
weekend before they eloped from the facility of
their trying to access the phone to call this guy
and leave the facility.

-The House Manager, staff #1 or staff #2
provided no response to being informed about the,
girls (clients) plan to leave the facility.

-"The girls (clients) were plotting all day; kept
saying they can't wait to get out of here.”

-On 1/19/26, the date of the incident, she had
made dinner and the sink was clogged and
requested help to unclog the sink.

-Staff #2 went into the kitchen to assist with
unclogging the kitchen sink.

-She went outside to her car to get a soda from
her trunk.

-The drink was in a can, so she was not allowed
to bring the drink on the unit, so she stoad in the
doorway of the House Manager office and drank
the soda.

«| heard three booms like someone was kicking
the doors."

-"l was told the girls (clients) had a running start
from the hallway and kicked through the doors.
-"[House Manager] and | yelled for them to
comeback, but they kept going. | went and got
my car keys and jumped in my car to go
searching."

-She along with the House Manager and staff #2
all searched for the clients in their cars.

-She was not aware of the clients not having
goals or strategies to address elopement.

Interview with former staff #6 was unsuccessful.
Attempted phone calls were made on 1/30/26,
2/4/26, 2/5/26 and 2/6/26,

Voicemail was not set up and unable to leave a
message.

-Requested assistance from the House Manager
and the Executive Director on 1/30/26 to make
Division of Health Service Regula

STATE FORM

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

| vat

i

t

K continuation sheet 9 of 12

LaGuit

PRINTED: 02/26/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(42) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c

B. WING 02/13/2026

MHL.004-016

NAME OF PROVIDER OR SUPPLIER
CORNERSTONE TREATMENT FACILITY

STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
WADESBORO, NC 28170

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST 8E PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

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

DEFICIENCY)

V 112] Continued From page 9

contact.

-Both the House Manager and the Executive
Director stated they called and she did not
respond to their calls.

Interview on 2/5/26 with the House Manager
revealed:

-She was not in the building when the 1/19/26
elopement incident occurred.

-She was getting off work and heading to her car.
-"l grabbed arm of [client #1] as she was going by
but she jerked away and kept going.”

-She returned back in the building and contacted
the Executive Director and then called the police,
~The door on the unit remained locked. The
glass door and the door to enter the office area
are always unlocked. The door to the conference
room, door to exit the conference room and the
exit door on the hallway is locked as well.”

«This is the longest clients have been away from
the facility. Normally we are able to locate them.”

Interview on 2/13/26 with the Director of
Operations revealed:
-The facility was staff secure and not a locked
facility.
-The main entrance door and door entering the
administrative offices are not locked.
-The exit door on the hal] with the client
bedrooms, kitchen, conference room, door
leaving the conference room and door to the unit
are locked. ;
-Staff are to contact the House Manager, the
House Manager notifies the Executive Director
and the Executive Director notifies him.
-He was made aware of all elopements that occur
at the facility.
-He acknowledged client #1, former client #4,
former client #5 and former client #6 plans did not
have strategies to address elopement.

Division of Health Service Regulation

STATE FORM t008

lLacut1 H continuation sheet 10 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES {(X1} PROVIDER/SUPPLIER/CLIA.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL004-016
NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

PRINTED: 02/26/2026
FORM APPROVED

(%2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

c

Ewing 02/43/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD

WADESBORO, NC 28470

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

V 112] Continued From page 10

Review on 2/13/26 of the Plan of Protection
written by the Chief Executive Officer dated
2/13/26 revealed: "What immediate action will
the facility take to ensure the safety of the
consumers in your care? 1. Upon initial review of
incoming admission documentation both he
clinician and care manager will access all prior Tx
(treatment) goals and address pertinent concerns
such as elopement during the Intake and
development of PCP and clinical goals. 2. All
goals will be reviewed at the initial Child and
Family Team meeting (PCP Goals) with the Tx
team. Clinical will review ail therapy goals of new
admissions during the monthly Clinical Team
meeting and address prior, existing and new Tx

goal concerns. Describe your plans to make sure

the above happens. Care management and
Clinical will revise current documentation to
capture prior existing and new treatment goal
concerns upon admission and ongoing with
monthly reviews at the CFT meetings. This will
include both clinical and PCP Tx goals. All
documentation will be reviewed and updated over
the next 45 days by the c/s next CFT review

Clients at the facility had diagnoses of Adjustment
Disorder with Mixed Disturbance of Emotions,
Attention Deficit Hyperactivity Disorder, Disruptive
Mood Dysregulation Disorder, Generalized
Anxiety Disorder, Oppositional Defiant Disorder
and Post Traumatic Stress Disorder. Client #1,
former client #4, former client #5 and former
client 4 all had history of elopement. There

were no goals and strategies in any of their PCP’s

addressing the elopement. Former client #4
eloped from a previous placement with the
26-year-old. Former client #4 and former client
#6 eloped together on 12/4/25. Client #1, former
Division of Health Service Regulation
STATE FORM

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

10
PREFIX
TAG

ose Lasun Mt continuation sheet 11 of 12

PRINTED: 02/26/2026
_ FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES | (X1) PROVIDERISUPPLIER/CLIA (0X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

c
MHL004-016 B. WING 02/13/2026

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

129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

V 112] Continued From page 11

client #4 and former client #5 all eloped together
on 1/19/26. The local police focated former client
#4 on 1/21/26 thirty-one miles away from the
facility. Once taken into custody the adult male
shared the lacations of client #1 and former client
#5. Client #1 was located on 1/22/26 eighty miles
away from the facility and former client #5 was
located on 1/21/26 forty-two miles from the

facility.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

Division of Health Service Regulation
STATE FORM Ld LaGcuti M continuation sheet 12 of 12

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 01/23/2026
FORM APPROVED

Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care
facility or to a patient or client.

Division of Health Service Regulation

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

STATE FORM

6899

KGD711

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
Acomplaint survey was completed on January
15, 2026. The complaints were unsubstantiated
(intake #NC00234690and NC00234849).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.
This facility is licensed for 12 and has a current
census of 9. The survey sample consisted of
audits of 3 current clients.
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

(X6) DATE

If continuation sheet 1 of 12

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to ensure the Health Care Personnel
Registry (HCPR) was notified of an allegation of
abuse against the Former Staff. The findings are:

Review on 1/8/26 of the facility's in-house incident
report dated 8/5/25 revealed:

-"On October 29, 2025 at approximately 5:40pm,
a verbal altercation occurred between the client
and staff. Staff involved removed themselves
from the community area and were relocated to
the administrative office area. The client
attempted to break down the door between the
client and the staff, but was unsuccessful.
[Former Staff #2] reported that he blocked the
door to prevent the [client #1] from entering the
unauthorized area and that he then smashed his
finger on the door. The [client #1] reported that
[Staff #1] called her a b***h and [Former Staff #1]
pushed her. [Staff #1] denied these allegations.
No other injuries were reported to [RN]. [Client
#1] denied any need for medical assistant. States
she is fine. End of report."

Review on 1/8/26 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

-There was no report submitted for the allegation

Division of Health Service Regulation

STATE FORM

6809

KGD711

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 132] Continued From page 1 V 132

If continuation sheet 2 of 12

Division of Health Service Regulation

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

MHL004-016

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/23/2026

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

CORNERSTONE TREATMENT FACILITY

WADESBORO, NC 28170

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
01/15/2026

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 132] Continued From page 2

by Client #1, that [Former Staff #1] was physically
abusive.

Interview on 1/8/26, 1/9/26, and 1/13/26 with the
House Manager revealed:

-"| didn't complete the incident report, and | did
not notify (HCPR)."

-"| am not responsible for notifying HCPR or
completing the IRIS report."

-"Management had dropped the ball."

Interview on 1/9/26 and 1/14/26 with the Qualified
Professional (QP) revealed:

-"| didn't do the IRIS report of the incident that
happened on October 29, 2025."

-"The HCPR wasn't notified because the IRIS
report was completed."

Interview on 1/14/26 with the Director of
Operations revealed:

-"| was not aware of the allegations that were
made against [FS #1] pushing [client #1] until
recently."

-"| told management at the facility that if anything
happens whether it's small or large | need to
know."

-"If | had known about the allegation | would have
reported to entities involved myself."
-"Management at the facility had dropped the
ball."

-He confirmed the agency failed to report
allegations of abuse to HCPR.

V 366} 27G .0603 Incident Response Requirements

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and

Division of Health Service Regulation
STATE FORM

V 132

V 366

6809

If continuation sheet 3 of 12

PRINTED: 01/23/2026

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
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 3 V 366

implement written policies governing their
response to level |, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;

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

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

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

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

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

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and

Division of Health Service Regulation
STATE FORM

6809

KGD711

If continuation sheet 4 of 12

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY

(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal
review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

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

(B) gather other information needed;

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

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

Division of Health Service Regulation
STATE FORM

6809

KGD711

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 4 V 366

If continuation sheet 5 of 12

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 5 V 366
Rule .0604;
(B) the LME where the client resides, if
different;
(C) the provider agency with responsibility

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

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to implement a policy governing their
response to Level Il and Level Ill incidents as
required. The findings are:

Review on 1/8/26 of the facility's in-house incident
report dated 8/5/25 revealed:

-"On October 29, 2025 at approximately 5:40pm,
a verbal altercation occurred between the client
and staff. Staff involved removed themselves
from the community area and were relocated to
the administrative office area. The client
attempted to break down the door between the
client and the staff, but was unsuccessful.
[Former Staff #2] reported that he blocked the
door to prevent the [client #1] from entering the
unauthorized area and that he then smashed his
finger on the door. The [client #1] reported that
[Staff #1] called her a b***h and [Former Staff #1]
pushed her. [Staff #1] denied these allegations.
No other injuries were reported to [RN]. [Client

Division of Health Service Regulation
STATE FORM

6809

KGD711

If continuation sheet 6 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/15/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

#1] denied any need for medical assistant. States
she is fine. End of report."

Review on 1/8/26 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

-There was no report submitted for the allegation
by [Client #1], that [Former Staff #1] was
physically abusive.

-There was no documentation to determine: The
cause of the incident; If the facility developed and
implemented corrective measures according to
the provider specified timeframes not to exceed
45 days; no measures to prevent similar incidents
according to provider specified timeframes not to
exceed 45 days and assigning person(s) to be
responsible for implementation of the corrections
and preventive measures.

Interview on 1/8/26, 1/9/26, and 1/13/26 with the
House Manager revealed:

-"| didn't complete the incident report, and | didn't
do the IRIS report."

-"| am not responsible for completing the IRIS
report."

-"| thought when [client #1] recanted her story that
we didn't have to do the IRIS report."

Interview on 1/9/26 and 1/14/26 with the Qualified
Professional (QP) revealed:

-"| didn't do the IRIS report of the incident that
happened on October 29, 2025."

-"The IRIS report was not completed by the
[Administrative Assistant] because she wasn't
emailed the incident."

-"Management had dropped the ball."

Interview on 1/14/26 with the Director of
Operations revealed:
-"| was not aware of the allegations that were

Division of Health Service Regulation

STATE FORM

6809

KGD711

(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 6 V 366

If continuation sheet 7 of 12

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

Division of Health Service Regulation
STATE FORM

6809

KGD711

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 7 V 366
made against [FS #1] pushing [client #1] until
recently."
-"If | had known about the allegation | would have
reported to entities involved myself."
-"Management at the facility had dropped the
ball."
-He confirmed the facility failed to implement a
policy governing their response to Level Il and
Level Ill incidents as required.
V 367] 27G .0604 Incident Reporting Requirements V 367

If continuation sheet 8 of 12

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY

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

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

KGD711

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 8 V 367

If continuation sheet 9 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
01/15/2026

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure an incident was reported
to the Local Management Entity/Managed Care
Organization (LME/MCO) for the catchment area
where services are provided within 72 hours of
becoming aware of the incident. The findings are:

Based on record review and interviews, the
facility failed to implement a policy governing their
response to Level Il and Level Ill incidents as
required. The findings are:

Review on 1/8/26 of the facility's in-house incident
report dated 8/5/25 revealed:

-"On October 29, 2025 at approximately 5:40pm,
a verbal altercation occurred between the client
and staff. Staff involved removed themselves
from the community area and were relocated to
the administrative office area. The client

(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 9 V 367

Division of Health Service Regulation
STATE FORM

6809

KGD711

If continuation sheet 10 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/23/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/15/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

attempted to break down the door between the
client and the staff, but was unsuccessful.
[Former Staff #2] reported that he blocked the
door to prevent the [client #1] from entering the
unauthorized area and that he then smashed his
finger on the door. The [client #1] reported that
[Staff #1] called her a b***h and [Former Staff #1]
pushed her. [Staff #1] denied these allegations.
No other injuries were reported to [RN]. [Client
#1] denied any need for medical assistant. States
she is fine. End of report."

Review on 1/8/26 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

-There was no report submitted for the allegation
by [Client #1], that [Former Staff #1] was
physically abusive.

Interview on 1/8/26, 1/9/26, and 1/13/26 with the
House Manager revealed:

-"| didn't complete the incident report, and | didn't
do the IRIS report."

-"| am not responsible for completing the IRIS
report."

-"| thought when [client #1] recanted her story that
we didn't have to do the IRIS report."

Interview on 1/9/26 and 1/14/26 with the Qualified
Professional (QP) revealed:

-"| didn't do the IRIS report of the incident that
happened on October 29, 2025."

-"The IRIS report was not completed by the
[Administrative Assistant] because she wasn't
emailed the incident."

-"Management had dropped the ball."

Interview on 1/14/26 with the Director of
Operations revealed:

-"| was not aware of the allegations that were
made against [FS #1] pushing [client #1] until

Division of Health Service Regulation

STATE FORM

6809

KGD711

(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 10 V 367

If continuation sheet 11 of 12

Division of Health Service Regulation

PRINTED: 01/23/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 01/15/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 11 V 367

recently."

-"If | had known about the allegation | would have
reported to entities involved myself."
-"Management at the facility had dropped the
ball."

-He confirmed the facility failed to report the
above incidents to LME/MCO within 72 hours.

Division of Health Service Regulation
STATE FORM

6809

KGD711

If continuation sheet 12 of 12

inspection_type: MHLCS Complaint


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

raw_content:
PRINTED: 11/26/2025

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
MHL004-016 11/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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, complaint and follow up survey was
completed on November 21, 2025. The complaint
was unsubstantiated (intake #NC00233946).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.
This facility is licensed for 12 and has a current
census of 10. The survey sample consisted of
audits of 3 current 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:
Based on record reviews and interviews the

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

STATE FORM If continuation sheet 1 of 3

6899

C2SK11

TITLE

(X6) DATE

Division of Health Service Regulation

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

MHL004-016

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

11/21/2025

(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 1 Vv 114

facility failed to ensure fire and disaster drills were
conducted quarterly and on each shift. The
findings are:

Review on 11/19/25 of the facility's fire drill log
from March 2025 through November 2025
revealed:

-There was no fire drills conducted for the 2nd
quarter (April, May, and June).

-There was no 3rd shift (12am-8am) drills
conducted.

Review on 11/19/25 of the facility's disaster drill
log from March 2025 through November 2025
revealed:

-There was no disaster drills conducted for the
2nd quarter (April, May, and June).

-There was no 3rd shift (12am-8am) drills
conducted.

Interview on 11/19/25 with the House Manager
revealed:

-"| didn't know | was supposed to do 3rd drills
while the clients were sleeping."

-"As | was transitioning to the [House Manager] in
March 2025, some of the drills didn't get done."

Interview on 11/20/25 with the Director of
Operations revealed:

-"| don't why the fire or disaster drills weren't done
on 3rd shift."

-"The [House Manager] was supposed to make
sure the drills were being done."

-"There are no excuses why the drills weren't
being done."

-"He confirmed the facility failed to ensure fire
and disaster drills were conducted quarterly on
each shift."

Division of Health Service Regulation
STATE FORM

6809

C2SK11

If continuation sheet 2 of 3

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

11/21/2025

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 interviews, the facility
was not maintained in a safe, clean, attractive,
orderly manner and kept free from offensive odor.
The findings are:

Observation on 11/18/25 at approximately
8:45AM revealed:

-Bedroom #1 had four broken blinds at the top of
the window. There was paint peeling on the wall
by the first bed and inside the second closet.
-There were no blinds in the kitchen window.

Interview on 11/18/25 with the House Manager
revealed:

-"[Client #3] had just pulled the blinds down in
bedroom #1 and the kitchen."

-"| haven't had a chance to get maintenance over
to replace the blinds because it just happened."

Interview on 11/20/25 with the Director of
Operations revealed:

-"| didn't know the blinds were missing."

-"| will have maintenance over to replace the
blinds and paint the walls."

-He confirmed that the facility was not maintained
in a safe, clean, attractive, orderly manner and
kept free from offensive odor.

This is a recite and must be corrected in 30 days.

Division of Health Service Regulation
STATE FORM

6809

C2SK11

(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 2 V 736
V 736] 27G .0303(c) Facility and Grounds Maintenance V 736

If continuation sheet 3 of 3

inspection_type: MHLCS Annual, Complaint, and Follow-up


raw_content:
Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/04/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL004-016 03/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 Vv 000

Acomplaint survey was completed on March 31,
2025. The complaint were unsubstantiated
(intake #NC00227756). No deficiencies were
cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

This facility is licensed for 12 and has a current
census of 10. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

VHZI11

TITLE (X6) DATE

If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL004-016

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY

WADESBORO, NC 28170

PRINTED: 02/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

02/07/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000!

V 736|

INITIAL COMMENTS

An annual and follow up survey was completed
on February 7, 2025. A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

This facility is licensed for 12 and has a current
census of 9. The survey sample consisted of
audits of 3 current clients.

27G .0303(c) Facility and Grounds Maintenance

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 interviews, the facility
was not maintained in a safe, clean, attractive,

orderly manner and kept free from offensive odor.

The findings are:

Observation on 2/6/25 at approximately 9:00 AM
revealed:
-Bedroom #1- The upper left side of the blind

were missing three pieces. Paint peeling on walls.

-Room #2- The upper left side of the blind were
missing four pieces. Paint peeling on walls.
-Room #3- The upper left side of the blind were
missing three pieces. Paint peeling on both sides
on the column connected to the closet.

-Room #4- Paint was peeling on walls.

-Room #5- Paint peeling on both sides on the
column connected to the closet.

V 000

V 736

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

STATE FORM

6899

LDRN11

TITLE

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

02/07/2025

PROVIDER'S PLAN OF CORRECTION

-Room #6- Paint peeling on walls and left side of
column connected to the closet.

-Room #7- The upper left side of the blind were
missing four pieces.

-Room #9- Paint peeling on walls. Writing on the
wall in red by the light switch.

-Paint was peeling on both hallway walls in the
bedroom area.

Interview on 2/6/25 with the Senior Team Leader
revealed:

-"The clients are tearing the blinds down."
-"Maintenance are starting to cover up the holes
where the clients can enter behind the plexiglass
to tear up the blinds."

-"Maintenance came and putty all the holes in the
wall. They said that they will be back to paint the
walls next week.

-"| did not realize that the blinds were missing."

Interview on 2/7/25 with the Executive Director
revealed:

-"Maintenance molded and putted the holes on
the walls."

-"The paint they had did not match the color on
the wall. They had to order the right color of paint
and wait for it to come in."

-"| did not know the blinds were missing.

-"| didn't pay it any attention."

Division of Health Service Regulation
STATE FORM

6809

LDRN11

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (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)
V 736 | Continued From page 1 V 736

If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Follow-up


raw_content:
PRINTED: 07/30/2024

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
MHL004-016 07/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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

A follow up survey was completed on July 23,
2024. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

This facility is licensed for 12 and has a current
census of 12. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

6PWU11

TITLE (X6) DATE

If continuation sheet 1 of 1