facility_name: A Clear Path Group Home

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 11/14/2025

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL-013-24 11/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2301 CENTERGROVE ROAD
A CLEAR PATH GROUP HOME
KANNAPOLIS, NC 28083
(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

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

STATE FORM

V 000} INITIAL COMMENTS

An annual survey was completed on November
13, 2025. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental Disability.

This facility is licensed for 6 and has a current
census of 4. The survey sample consisted of
audits of 3 current clients.

V 000

6808 2MOG11

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual


state: NC

facility_name: Monroe Road

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 12/10/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346303 12/03/2025

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

MONROE ROAD
CHARLOTTE, NC 28212

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 000} | INITIAL COMMENTS {W 000}

Arevisit was conducted on 12/3/25 for all
deficiencies cited on 9/24/25. All deficiencies
have been corrected, and no new deficiencies
were found. The facility is in compliance with all
regulations surveyed.

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN13 Facility ID: 924981 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

PRINTED: 11/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
11/10/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

ID PROVIDER'S PLAN OF CORRECTION (x5)

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

W 000 | INITIAL COMMENTS

Arevisit was conducted on 11/10/25 for the
condition of participation cited on 9/24/25. The
condition of participation deficiencies have been
corrected. Standard level deficiencies remain out
of compliance until the 60 day follow-up.

{W 369} | DRUG ADMINISTRATION

CFR(s): 483.460(k)(2)

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.
This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure medications
were administered in accordance with physician's
orders. This affected 2 client (#2 and #4)
observed during medication administration. The
finding is:

A. The facility failed to ensure that client #4's
medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
client #4 was observed to enter the medication
room at 7:56 AM. Further observation revealed
client #4 to exhibit behaviors including screaming
and throwing items in the medications room. Staff
responded by escorting client #4 to her bedroom
at which time she calmed down. Continued
observation revealed staff A to prepare and
administer the following medications to client #4
Buspirone, CA CIT/Vit D, Senna-Time,
Benztropine, Divalproex, Ferusol, Vit B3, Omega
3 Fish Oil, Levothyroxine, Meloxicam,
Alendronate, Clonidine, Ingrezza, Lactulose.
Continued observation revealed staff A to take the

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

W 000

{W 369}

TITLE (X6) DATE

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

program participation.

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

Event ID: TMRN12

Facility ID: 924981 If continuation sheet Page 1 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 11/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
11/10/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

medications to client #4 in her bedroom and client
#4 to take all medications at 8:05 AM.

Review on 9/24/25 of client #4's physician's
orders dated 9/24/25 revealed that the
Levothyroxine is to be administered at 6:00 AM
and the Lactulose is to be administered at 5:00
PM.

Interview on 9/27/25 with the nursing supervisor
confirmed that client #4's Levothyroxine and
Lactulose were administered outside of the time
prescribed for each and that all medications
should be administered according to the
physicians' orders.

B. The facility failed to ensure that client #2's
medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
client #2 was observed to enter the medication
room at 8:15 AM. Further observation revealed
staff A to prepare and administer the following
medications to client #2: Lorazepam, Omega 3
Fish Oil, Cetirizine, Duloxetine, Vit D3, Lo
Loestrine, Ciclopirox. Continued observation
revealed client #2 to take all medications at 8:20
AM.

Review on 9/24/25 of client #2's physician's
orders dated 7/15/25 revealed that all
medications are to be administered at 7:00 AM.

Interview on 9/27/25 with the nursing supervisor
confirmed that all of client #2's medications
should have been administered between 6:00 AM
and 8:00 AM and that all medications should be
administered according to the physicians' orders.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 369} | Continued From page 1 {W 369}

Facility ID: 924981 If continuation sheet Page 2 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 11/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
11/10/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

CFR(s): 483.460(1)(2)

The facility must keep all drugs and biologicals
locked except when being prepared for
administration.

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure all medications and biologicals
remained locked except when being prepared for
administration. The finding is:

Morning observations in the home on 9/24/25 at
8:03 AM revealed staff A to leave the medication
area and leave 14 medications, including 1
controlled medication, on a desk. Further
observations revealed that there is no door on the
medication room, just a privacy screen which is
pulled across the door when clients are in the
room. Continued observations revealed all staff
to be away from the medication room for 5
minutes with the medications out on the desk.

Interview on 9/24/25 with the nursing supervisor
revealed that all medications should be locked
inside the medication cart when staff are not
directly supervising the medications.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 382} | DRUG STORAGE AND RECORDKEEPING {W 382}

Facility ID: 924981 If continuation sheet Page 3 of 3


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 10/03/2025. |

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

{X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346303

NAME OF PROVIDER OR SUPPLIER

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

ACTIVE TREATMENT SERVICES
CFR(s): 483.440

The facility must ensure that Specific active
treatment services requirements are met.

This CONDITION is not met as evidenced by:
The team failed to ensure clients received a
continuous active treatment program with
sufficient frequency to support achievement of the
objectives as identified in their person-centered
plans (PCPs) (W249) and to ensure that data
relative to the accomplishment of objective
criteria was documented in measurable terms
(W262).

The cumulative effect of these systemic practices
resulted in the facility's failure to provide
Statutorily mandated active treatment services to
the clients.

W 196 | ACTIVE TREATMENT
CFR(s): 483,440(a)(1)

Each client must receive a continuous active
treatment program, which includes aggressive,
consistent implementation of a program of
specialized and generic training, treatment, health
services and related services described in this
subpart, that is directed toward:

(i) The acquisition of the behaviors necessary for
the client to function with as much self
determination and independence as possible; and

(ii) The prevention or deceleration of regression
or loss of current optimal functional status.

This STANDARD is not met as evidenced by:
Based on observations, record reviews and

(%2) MULTIPLE CONSTRUCTION
A. BUILDING.

B. WING

STREET ADORESS, CITY. STATE, ZiP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

wi95] W195

The Facility Administrator (FA) and
Qualified Professional (QP) will
ensure all Direct Support
Professionals (DSP) stat members
are retrained and understand the
definition of Active Treatment
including the required frequen
needed to support achievemeni
of the objectives outlined in each
permon supporteds' Person Centered
lan (PCP). This will be completed
through In-Service training,
Assessments and ongoing monitoring
by the IDT members. This will be
monitored through monthly House
Meetings, CORE team meetings and
QAPI Meetings to ;
ensure active treatment is being
completed in the facility daily.

Cross referenced with W196, W249
and W252.

RECEIVED

13 2025

DHSR-MH Licensure Sect

Continued pg 2

TITLE

OR
Director of Organic Growth - NC.
ementtihd ficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions ) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a pian of correction is provided For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

10/8/2025

FORM GMS-2567 (02-98) Previous Versions Onsoiete ‘Event ID: TMRN11 Facility 10 924961 if continuation sheet Page 1 of 13

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

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

346303

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

W 196 | Continued From page 1
interviews, the facility failed to ensure that 5 of 5
audit clients (#1, #2, #3, #4 and #5) received

continuous active treatment services throughout
their day.

A. Cross reference W249. The facility failed to
ensure 4 of 5 audit clients (#1, #2, #3 and #4)
received a continuous active treatment Program
with sufficient frequency to support achievement
of the objectives as identified in their
person-centered plans (PCPs).

B. Cross reference W252. The facility failed to
ensure data related to the accomplishment of
objective criteria was documented in measurable
terms. This affected 5 of 5 audit clients (#1, #2,
#3, #4 and #5).

PROGRAM IMPLEMENTATION

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

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

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to ensure that 4 of 5
audit clients (#1, #2, #3 and #4) received a
Continuous active treatment program consisting
of needed interventions and services as identified
in their Person-Centered Plans (PCPs). The

FORM CMS-2567(02-89) Previous Versions Obsolete Event iD: TMRNIt

(42) MULTIPLE CONSTRUCTION

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Wwi96
The QP and Habilitation Specialist (HS) will in-
service all DSP staff on each person's PCP,
current obectives, hoott srasiats and how to provide

Ing ar atmen' person supported
in ihe fealty, This will be monitored by IDT members|
completing observations through two (2)
Interaction Assessments per week for 1 month
and then on an ongoing routine basis. The IDT
member will review the results of the Interaction

t with the DSPs on shift providing

immediate feedback and training as needed. This
process will be monitored during the monthly CORE
team meetings and QAP! meetings. In the future
the QP will ensure all DSP staff are in-service
trained on Active Treatment when hired and on
a monthly basis at the House Meetings.

Cross referenced with W195, W249 & W252.

11/23/2025

W249
The QP & HS will in-service all of the DSP staff on
each person supporteds' required ad:
equipment. The QP & HS will ensure the facility has
all required adaptive equipment on hand along with
back up equipment for use at every meal or
appropriate activity. This will be monitored by the
ior members by completing two (2) Meal
Assessments per week for one (1) month and then
‘on an ongoing routine basis. The HS will also

a bi-monthly inventory of all adaptive
equipment and ensure replacement items are
purchased as needed. These ses will be
monitored during monthly team and QAPI
meetings. In the future the QP will ensure all
OSP staff are in-service trained on all adaptive
equipment for each person along with appropriate
meaitime guidelines.

Cross reference with W195, W196 and W252.

Continued pg 8

Facility ID; 924981 Ifcontinuation sheet Page 2 of 13

PRINTED: 10/03/2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING,

346303 BL WING.

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

7621 MONROE ROAD
CHARLOTTE, NC 28212

MONROE ROAD

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

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

Continued From page 2
findings are:

A. During afternoon observations in the group
home on 9/23/25 from 4:30 PM until 6:00 PM
Client #1 was observed in the common areas of
the home unengaged in any formal training or
activities except for approximately 5 minutes
when staff assisted her to complete a puzzle.
Continued observations during this period
revealed staff to place an electronic keyboard on
client #1's lap and direct her to play it without
Offering client #1 a choice of activities. Client #4
did not engage with the keyboard.

During morning observations in the group home
On 9/24/25 from 7:06 AM until 7:39 AM, client #1
was observed to wash her hands and eat her
breakfast. Throughout the breakfast observation,
client #1 was observed to drop food from her
mouth onto her clothing protector several times,
while staff did not prompt her to close her mouth
while eating. At 7:40 AM, staff assisted client #1
to a recliner in the living room without prompting
her to take her dishes to the kitchen. Continued
observation revealed that between 7:40 AM and
8:10 AM, client #1 sat in the recliner unengaged
with people or activities and that, at 8:10 AM,
Client #1 got up from the recliner and walked
unassisted by staff to her bedroom, where she
remained until the end of observations at 8:30
AM.

Review on 9/24/26 of client #1's PCP dated
4/9/25 revealed she has formal training objectives
including cooperation during dental visits,
minimizing target behaviors, wiping herself after
using the bathroom, signaling staff that she needs
to use the bathroom, participating in activities of
choice, closing her mouth while eating, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11 Facility ID: 924981 If continuation sheet Page 3 of 13

PRINTED: 10/03/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICE:

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

346303 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

W 249 | Continued From page 3
Continuing her oral hygiene routine, as well as
informal training objectives including participation
in daily chores, participation in monthly fire drilis,
Participation in more activities, staying on task,
meal preparation and taking medications. Further
review of the PCP revealed that client #1 requires
one on on support and stand-by assistance
during ambulation and transfers due to her history
of seizures.

Interview with the habilitation specialist (HS) and
the qualified intellectual disabilities professional
(QIDP) confirmed that client #1 should be
prompted by staff to participate in formal and
informal training objectives as required.

B. During observations in the group home on
9/23/25 from 4:30 PM until 6:00 PM, client #2 was
observed in the common areas of the home
unengaged in any formal training or integrative
activities, except between 5:15 PM and 5:35 PM
when she was engaged in a game of UNO with a
staff member.

During morning observations in the group home
on 9/24/25 from 7:06 AM until 7:39 AM, client #2
was observed to wash her hands and eat her
breakfast. Further observation revealed client #2
to take her dishes to the kitchen and move to a
couch in the living room at 7:37 AM. Continued
observation revealed client #2 to remain on the
living room couch with a box of checkers in her
lap from 7:37 AM until the end of observations at
8:30 AM, with only passing interactions with staff.

Review on 9/24/25 of client #2's PCP dated
6/16/25 revealed she has formal training
objectives including teeth brushing, shaving,
participation in podiatry appointments,

FORM CMS-2567(02-89) Previous Versions Obsolete Event ID TMRN11 Facility ID: 924961 If continuation sheet Page 4 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES

STATEMENT OF DEFICIENCIES

IDENTIFICATION NUMBER:

34G303

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

W 249 | Continued From page 4
participation in 1 community outing of her choice
weekly, minimizing disruptive behaviors,
continuing to respect the rights of others, walking
for 20 minutes 3 times per week, participating in
meal preparation by setting the table 2 times per
week, and maintaining a healthy weight. Further
review of the PCP revealed that client #2 has
informal training objective including participation
in daily chores, participating in monthly fire drills
and maintaining safety habits when riding the
van.

Interview with the HS and the QIDP confirmed
that client #2 should be prompted by staff to
participate in formal and informal training
objectives as required.

C. During observations in the group home on
9/23/25 from 4:30 PM until 5:00 PM, client #3 was
observed to be in her bed and awake. Further
observations between 5:02 PM and 5:40 PM
revealed client #8 to be in the living unengaged in
any formal training or integrative activities, except
between 5:02 PM and 5:20 PM when she was
engaged in a puzzle and a game of UNO with a
staff member.

During morning observations in the group home
on 9/24/25 from 7:06 AM until 7:39 AM, client #3
was observed to wash her hands and eat her
breakfast. Further observation revealed client #3
to take her dishes to the kitchen at 7:45 AM and
return to her bed, where she remained until the
end of observations at 8:30 AM without engaging
in structured activities or interacting with others
outside of medication administration.

Review on 9/24/25 of client #3's PCP dated
9/13/24 revealed she has formal training

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID: TMRN11

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

B. WING

PRINTED: 10/03/2025
FORM APPROVED

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

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

If continuation sheet Page 5 of 13

Facility ID’ 924981

PRINTED: 10/03/2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICA OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (42) MULTIPLE CONSTRUCTION

ANO PLAN OF CORRECTION

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

7621 MONROE ROAD

CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

MONROE ROAD

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

Continued From page 5
objectives including pulling her pants up during
dressing and toileting, washing her hands after
using the restroom and completing a puzzie.

Interview with the HS and the QIDP confirmed
that client #3 should be prompted by staff to
Participate in formal and informal training
objectives as required.

D. During observations in the group home on
9/23/25 from 4:30 PM until 6:00 PM, client #4 was
observed in the living room of the home, sitting
quietly on a couch, unengaged in any formal
training or integrative activities, except between
4:45 PM and 5:00 PM when she set the table for
dinner and for approximately 5 minutes when she
walked laps in the home with staff.

During observations in the group home on
9/24/25 from 6:55 AM until 7:45 AM, client #3 was
observed to wash her hands, help set the
breakfast table, and eat breakfast. Further
observation at 7:45 AM revealed client #4 to
remove her dishes to the kitchen, wash her
hands, and sit quietly on a chair in the living room
Until 8:30 when observations ended, except for a
brief time when she went to her room, then
returned to the living room chair.

Review on 9/24/25 of client #4's PCP dated
9/12/26 revealed she has formal training
objectives including preparing a beverage for the
meal, taking out the trash, walking for 15 minutes
2 times per week, using the restroom every two
hours when prompted by staff, participating in 1
activity per day at the vocational center and
brushing her teeth daily.

Interview with the HS and the QIDP confirmed
FORM CMS-2567 (02-89) Previous Versions Obsolete Event ID: TMRN11 Facility ID: 924981 If continuation sheet Page 6 of 13

PRINTED: 10/03/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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

7621 MONROE ROAD

CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

MONROE ROAD

(X4) 1D
PREFIX
TAG

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

Continued From page 6
that client #4 should be prompted by staff to
Participate in formal and informal training

objectives as required.

E. Afternoon observations in the group home on
9/23/25 revealed client #3 to participate in the
dinner meal. Further observation revealed client
#3 to be furnished with the following adaptive
equipment: wrist weights, large handle spoon,
clothing protector, high sided divided dish and 2
cups with lids and straws, but no non-skid mat.
Continued observation revealed client #3 to
Struggle to pick up food during dinner from her
hands shaking.

Morning observations in the group home on
9/24/25 revealed client #3 to participate in the
breakfast meal. Further observation revealed
Client #3 to be furnished with the following
adaptive equipment: large handle spoon, clothing
protector, high sided divided dish and 2 cups with
lids and straws, but no non-skid mat and no wrist
weights. Continued observation revealed client #3
to struggle to pick up food and to get her spoon to
her mouth during breakfast due to her hands
shaking.

Review of records on 9/24/25 revealed a PCP for
client #3 dated 9/3/24 which lists client #3's

adaptive equipment as a high sided divided dish,
Shirt protector, large handle spoon, non-skid mat,
wrist weights, and a cup with lid and straw.

Interview with the QIDP revealed that client #3's
PCP is current and that the facility should have
made a non-skid mat available for client #3
during both meals and made wrist weights
available during the breakfast meal.

FORM CMS-2567(02-89) Previous Versions Obsolete Event ID: TMRN11 Facility ID: 924981 If continuation sheet Page 7 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

Continued From page 7
PROGRAM DOCUMENTATION
CFR(s): 483.440(e)(1)

Specified in client individual program plan

terms.

interviews, the facility failed to ensure data
relative to the accomplishment of objective
#4 and #5). The findings are:

A. Review on 9/24/25 of client #1's
Person-Centered Plan (PCP) dated 4/9/25

shift.
- Wipe after using the toilet: Data to be
collected daily on second shift.

been recorded as required.

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

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

Data relative to accomplishment of the criteria

Objectives must be documented in measurable

This STANDARD is not met as evidenced by:
Based on observations, record reviews and

Criteria was documented in measurable terms.
This affected 6 out of 5 audit clients (#1, #2, #3,

revealed formal training programs as follows:
- Participate in an activity to redirect her from
screaming: Data to be collected daily during first

- _ Use the restroom when prompted every two
hours: Data to be collected daily on first shift.

Review on 9/24/25 of client #1's computerized
Program data revealed that data was recorded on
only 28 of 116 days between 6/1/25 and 9/24/25.

Interview with the habilitation specialist (HS) and
the qualified intellectual disabilities professional
(QIDP) on 9/24/25 confirmed that the program
data are accurate and that program data has not

(X2) MULTIPLE CONSTRUCTION

7621 MONROE ROAD
CHARLOTTE, NC 26212

W252

to document each person suj

any ongoing job pe:

Event ID: TMRN11 Facility 10: 924981

STREET ADDRESS, CITY, STATE, ZIP COOE

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD 8E
GROSS-REFERENCED TO THE APPROPRIATE

The QP, HS and Residential Team Leader (RTL)
will in-service train all DSP staff

ipporteds' programs:
daily as programs and active treatment are complete,
in order to \strate the person's progress or
regress on tasks, activities and goals.
The HS will monitor each person's progress on their
goals monthly and implement programming

cha based on the person's
The AS wil in-service the DSP

minimum three (3) days per week, If the fequired
documentation is not present in the EHR, the QP
will address the DSP staff as ap) jate up to and
including Corrective Action. The FA will meet weel
socumentaon being carplsted ard ac
mentation com and to address
Ret oi issues. In the future
the QP will ensure all DSP staff are trained on
required documentation for each person supported.

Cross referenced with W195, W196 and W249.

Continued pg 14

PRINTED: 10/03/2025

on the requirement
is’ pi

progress of regress.
staf each month

are required. This
QP, HS and/or RTL

\f continuation sheet Page 8 of 13

PRINTED: 10/03/2025
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

346303

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

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

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

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

W 282 | Continued From page 8
B. Review on 9/24/25 of client #2's PCP dated
6/16/25 revealed formal training programs as
follows:

- _ Brush her teeth twice per day; Data to be
collected daily.

- _ Set the table 3 times per week: Data to be
collected daily on second shift.

- _ Walk for 20 minutes 3 times per week: Data
to be collected Monday, Wednesday and Friday
On second shift.

Review on 9/24/25 of client #2's computerized
Program data revealed that data was recorded on
only 45 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/25
Confirmed that the program data are accurate and
that program data has not been recorded as

required.

C. Review on 9/24/25 of client #3's PCP dated
9/13/24 revealed formal training programs as
follows:

- Pull up pants: Data to be collected daily.

- Wash hands after using the restroom: Data to
be collected daily on first shift.

Review on 9/24/25 of client #3's computerized
Program data revealed that data was recorded on
only 30 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/26
confirmed that the program data are accurate and
that program data has not been recorded as

required.

D. Review on 9/24/25 of client #4’s PCP dated
9/12/25 revealed formal training programs as
follows:

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID: TMRN11 Facility ID: 924981 If continuation sheet Page 9 of 13

PRINTED: 10/03/2025
FORM APPROVED
CENTERS FOR MEDICARE & MEDI OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X2) MULTIPLE CONSTRUCTION
‘AND PLAN OF CORRECTION ALBULOING

DEPARTMENT OF HEALTH AND ieurdp SERVICES

B. WING

eer eee
STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

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

Continued From page 9
- _ Prepare a beverage for the meal: Data to be
collected daily.

> Take trash bag out to the trash can: Data to
be collected daily.

- _ Walk for 15 minutes: Data to be collected
daily.

Review on 9/24/25 of client #4’s computerized
Program data revealed that data was recorded on
only 29 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/25
Confirmed that the program data are accurate and
that program data has not been recorded as

required.

E. Review on 9/24/25 of client #5's PCP dated
1/10/25 revealed formal training programs as
follows:

- _ Tolerate sitting in the living room, engaging in
an activity with staff/peers: Data to be collected
daily.

- Use the restroom every two hours when
Prompted by staff: Data to be collected daily on
first shift.

- _ Put dirty clothes in the hamper after bath:
Data to be collected daily on first shift.

- Walk for 15 minutes: Data to be collected
Monday, Wednesday and Friday on second shift.
- Wash hands after toileting: Data to be
collected daily on first shift.

Review on 9/24/25 of client #5’s computerized
Program data revealed that data was recorded on
only 35 of 116 days between 6/1/25 and 9/24/25.

Further record review revealed in-service training
tecords from 7/31/25, 8/21/25 and 9/18/25.
However, interviews and data review revealed

FORM CMS-2567(02-99) Previous Versions Obsolele Event ID: TMRINGT Facility 1D; 924961 \continuation sheet Page 10 of 13

PRINTED: 10/03/2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X2) MULTIPLE CONSTRUCTION

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

7621 MONROE ROAD
CHARLOTTE, NC 28212

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

MONROE ROAD

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

W 282 | Continued From page 10
staff are still failing to document data as desribed.
DRUG ADMINISTRATION

CFR(s): 483.460(k)(2)

The facility nurse will complete in- Medication
Administration training with ail Staff in the facility
by 11/23/2025 along with in-servicing all current
medication orders for each person supported wi

the DSP staff. The facility nurse will ensure
compliance toy all Medication yer
procedures by completing one ion
Observation with all DSP staff in the facility by
11/23/2025 and then on an ongoing and routine
basis. This process will be monitored during the
peatily CORE team and QAPI meetings. In the
future the nursing staff will train all DSP staff
administer medications as ordered by the
physician and follow the six (6) rights at each
medication pass.

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.
This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure medications
were administered in accordance with physician's
orders. This affected 2 client (#2 and #4)
observed during medication administration. The
finding is:

A. The facility failed to ensure that client #4's
medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
Client #4 was observed to enter the medication
room at 7:56 AM. Further observation revealed
Client #4 to exhibit behaviors including screaming
and throwing items in the medications room. Staff
responded by escorting client #4 to her bedroom
at which time she calmed down. Continued
observation revealed staffA to prapare and
administer the following medications to client #4
Buspirone, CA CIT/Vit D, Senna-Time,
Benztropine, Divalproex, Ferusol, Vit B3, Omega
3 Fish Oil, Levothyroxine, Meloxicam,
Alendronate, Clonidine, Ingrezza, Lactulose.
Continued observation revealed staff A to take the
Medications to client #4 in her bedroom and client
#4 to take all medications at 8:05 AM.

Review on 9/24/25 of client #4's physician's
orders dated 9/24/25 revealed that the

Continued pg 13

FORM CMS-2567(02-99) Previous Versions Obsolele Event ID: TMRN11 Faciiity 1D 924981 If continuation sheet Page 11 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES ORPORMAPERON

(X2) MULTIPLE CONSTRUCTION

A. BUILDING.

IDENTIFICATION NUMBER:

346303 B. WING

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

7621 MONROE ROAD
CHARLOTTE, NC 28212

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

MONROE ROAD

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

W 369] Continued From page 11

Levothyroxine is to be administered at 6:00 AM
and the Lactulose is to be administered at 5:00
PM.

Interview on 9/27/25 with the nursing supervisor
confirmed that client #4's Levothyroxine and
Lactulose were administered outside of the time
prescribed for each and that all medications
should be administered according to the
physicians’ orders.

B. The facility failed to ensure that client #2's
Medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
Client #2 was observed to enter the medication
room at 8:15 AM. Further observation revealed
staff A to prepare and administer the following
medications to client #2: Lorazepam, Omega 3
Fish Oil, Cetirizine, Duloxetine, Vit D3, Lo
Loestrine, Ciclopirox. Continued observation
fevealed client #2 to take all medications at 8:20
AM.

Review on 9/24/25 of client #2's physician's
orders dated 7/15/25 revealed that all
medications are to be administered at 7:00 AM.

Interview on 9/27/25 with the nursing supervisor
Confirmed that all of client #2's medications
should have been administered between 6:00 AM
and 8:00 AM and that all medications should be
administered according to the physicians’ orders.
DRUG STORAGE AND RECORDKEEPING W 382
CFR(s): 483.460(1)(2)

The facility must keep all drugs and biologicals

FORM CMS-2567(02-99) Previous Versions Obsolete Event 1D: TMRN11 Facility ID: 924981 If continuation sheet Page 12 of 13

PRINTED: 10/03/2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

‘STATEMENT OF DEFICIENCIES (X17) PROVIDER/SUPPLIERICLIA (2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION (IDENTIFICATION NUMBER:

ABUILDING

346303 8. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

Continued From page 12 te
is ef fs , ty
Based on observations and interviews, the facility Tried red reek Fobetitiee phate
failed to ensure all medications and biologicals Observation with each DSP staff by 11/23/25 and
remained locked except when being prepared for bathe Pinay Sone baa. in the futue the
administration. The finding is: in-service trained to keep all medications locked
unless being prepared for administration.

Moming observations in the home on 9/24/25 at
8:03 AM revealed staff A to leave the medication
area and leave 14 medications, including 1
controlled medication, on a desk. Further
observations revealed that there is no door on the
medication room, just a privacy screen which is
pulled across the door when clients are in the
foom. Continued observations revealed all staff
to be away from the medication room for 5
minutes with the medications out on the desk.

Interview on 9/24/25 with the nursing supervisor
revealed that all medications should be locked
inside the medication cart when staff are not
directly supervising the medications.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: TMRN11 Facility (D: 924981 lf continuation sheet Page 13 of 13

document_type: Plan of Correction


summary: Statement of deficiency - MHLCS Annual

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

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

ID PROVIDER'S PLAN OF CORRECTION (x5)

COMPLETION
DATE

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

W 195 | ACTIVE TREATMENT SERVICES

CFR(s): 483.440

The facility must ensure that specific active
treatment services requirements are met.

This CONDITION is not met as evidenced by:
The team failed to ensure clients received a
continuous active treatment program with
sufficient frequency to support achievement of the
objectives as identified in their person-centered
plans (PCPs) (W249) and to ensure that data
relative to the accomplishment of objective
criteria was documented in measurable terms
(W252).

The cumulative effect of these systemic practices
resulted in the facility's failure to provide
statutorily mandated active treatment services to
the clients.

ACTIVE TREATMENT

CFR(s): 483.440(a)(1)

W 196

Each client must receive a continuous active
treatment program, which includes aggressive,
consistent implementation of a program of
specialized and generic training, treatment, health
services and related services described in this
subpart, that is directed toward:

(i) The acquisition of the behaviors necessary for
the client to function with as much self
determination and independence as possible; and

(ii) The prevention or deceleration of regression
or loss of current optimal functional status.

This STANDARD is not met as evidenced by:
Based on observations, record reviews and

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

W 195

W 196

TITLE (X6) DATE

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

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

Facility ID: 924981 If continuation sheet Page 1 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

(x4) ID
PREFIX
TAG

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

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

(8)
COMPLETION
DATE

DEFICIENCY)

W 196 | Continued From page 1

interviews, the facility failed to ensure that 5 of 5
audit clients (#1, #2, #3, #4 and #5) received
continuous active treatment services throughout
their day.

A. Cross reference W249. The facility failed to
ensure 4 of 5 audit clients (#1, #2, #3 and #4)
received a continuous active treatment program
with sufficient frequency to support achievement
of the objectives as identified in their
person-centered plans (PCPs).

B. Cross reference W252. The facility failed to
ensure data related to the accomplishment of
objective criteria was documented in measurable
terms. This affected 5 of 5 audit clients (#1, #2,
#3, #4 and #5).

PROGRAM IMPLEMENTATION

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

W 249

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

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to ensure that 4 of 5
audit clients (#1, #2, #3 and #4) received a
continuous active treatment program consisting
of needed interventions and services as identified
in their Person-Centered Plans (PCPs). The

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

W 196

W 249

Facility ID: 924981

If continuation sheet Page 2 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

findings are:

A. During afternoon observations in the group
home on 9/23/25 from 4:30 PM until 6:00 PM
client #1 was observed in the common areas of
the home unengaged in any formal training or
activities except for approximately 5 minutes
when staff assisted her to complete a puzzle.
Continued observations during this period
revealed staff to place an electronic keyboard on
client #1's lap and direct her to play it without
offering client #1 a choice of activities. Client #1
did not engage with the keyboard.

During morning observations in the group home
on 9/24/25 from 7:06 AM until 7:39 AM, client #1
was observed to wash her hands and eat her
breakfast. Throughout the breakfast observation,
client #1 was observed to drop food from her
mouth onto her clothing protector several times,
while staff did not prompt her to close her mouth
while eating. At 7:40 AM, staff assisted client #1
to a recliner in the living room without prompting
her to take her dishes to the kitchen. Continued
observation revealed that between 7:40 AM and
8:10 AM, client #1 sat in the recliner unengaged
with people or activities and that, at 8:10 AM,
client #1 got up from the recliner and walked
unassisted by staff to her bedroom, where she
remained until the end of observations at 8:30
AM.

Review on 9/24/25 of client #1's PCP dated
4/9/25 revealed she has formal training objectives
including cooperation during dental visits,
minimizing target behaviors, wiping herself after
using the bathroom, signaling staff that she needs
to use the bathroom, participating in activities of

choice, closing her mouth while eating, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

Facility ID: 924981

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

If continuation sheet Page 3 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

continuing her oral hygiene routine, as well as
informal training objectives including participation
in daily chores, participation in monthly fire drills,
participation in more activities, staying on task,
meal preparation and taking medications. Further
review of the PCP revealed that client #1 requires
one on on support and stand-by assistance
during ambulation and transfers due to her history
of seizures.

Interview with the habilitation specialist (HS) and
the qualified intellectual disabilities professional
(QIDP) confirmed that client #1 should be
prompted by staff to participate in formal and
informal training objectives as required.

B. During observations in the group home on
9/23/25 from 4:30 PM until 6:00 PM, client #2 was
observed in the common areas of the home
unengaged in any formal training or integrative
activities, except between 5:15 PM and 5:35 PM
when she was engaged in a game of UNO with a
staff member.

During morning observations in the group home
on 9/24/25 from 7:06 AM until 7:39 AM, client #2
was observed to wash her hands and eat her
breakfast. Further observation revealed client #2
to take her dishes to the kitchen and move to a
couch in the living room at 7:37 AM. Continued
observation revealed client #2 to remain on the
living room couch with a box of checkers in her
lap from 7:37 AM until the end of observations at
8:30 AM, with only passing interactions with staff.

Review on 9/24/25 of client #2's PCP dated
6/16/25 revealed she has formal training
objectives including teeth brushing, shaving,

participation in podiatry appointments,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

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

Facility ID: 924981

If continuation sheet Page 4 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/24/2025

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

PROVIDER'S PLAN OF CORRECTION

ID (x8)

participation in 1 community outing of her choice
weekly, minimizing disruptive behaviors,
continuing to respect the rights of others, walking
for 20 minutes 3 times per week, participating in
meal preparation by setting the table 2 times per
week, and maintaining a healthy weight. Further
review of the PCP revealed that client #2 has
informal training objective including participation
in daily chores, participating in monthly fire drills
and maintaining safety habits when riding the
van.

Interview with the HS and the QIDP confirmed
that client #2 should be prompted by staff to
participate in formal and informal training
objectives as required.

C. During observations in the group home on
9/23/25 from 4:30 PM until 5:00 PM, client #3 was
observed to be in her bed and awake. Further
observations between 5:02 PM and 5:40 PM
revealed client #3 to be in the living unengaged in
any formal training or integrative activities, except
between 5:02 PM and 5:20 PM when she was
engaged in a puzzle and a game of UNO with a
staff member.

During morning observations in the group home
on 9/24/25 from 7:06 AM until 7:39 AM, client #3
was observed to wash her hands and eat her
breakfast. Further observation revealed client #3
to take her dishes to the kitchen at 7:45 AM and
return to her bed, where she remained until the
end of observations at 8:30 AM without engaging
in structured activities or interacting with others
outside of medication administration.

Review on 9/24/25 of client #3's PCP dated

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 | Continued From page 4 W 249

9/13/24 revealed she has formal training

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

Facility ID: 924981 If continuation sheet Page 5 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

objectives including pulling her pants up during
dressing and toileting, washing her hands after
using the restroom and completing a puzzle.

Interview with the HS and the QIDP confirmed
that client #3 should be prompted by staff to
participate in formal and informal training
objectives as required.

D. During observations in the group home on
9/23/25 from 4:30 PM until 6:00 PM, client #4 was
observed in the living room of the home, sitting
quietly on a couch, unengaged in any formal
training or integrative activities, except between
4:45 PM and 5:00 PM when she set the table for
dinner and for approximately 5 minutes when she
walked laps in the home with staff.

During observations in the group home on
9/24/25 from 6:55 AM until 7:45 AM, client #3 was
observed to wash her hands, help set the
breakfast table, and eat breakfast. Further
observation at 7:45 AM revealed client #4 to
remove her dishes to the kitchen, wash her
hands, and sit quietly on a chair in the living room
until 8:30 when observations ended, except for a
brief time when she went to her room, then
returned to the living room chair.

Review on 9/24/25 of client #4's PCP dated
9/12/25 revealed she has formal training
objectives including preparing a beverage for the
meal, taking out the trash, walking for 15 minutes
2 times per week, using the restroom every two
hours when prompted by staff, participating in 1
activity per day at the vocational center and
brushing her teeth daily.

Interview with the HS and the QIDP confirmed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

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

Facility ID: 924981 If continuation sheet Page 6 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

that client #4 should be prompted by staff to
participate in formal and informal training
objectives as required.

E. Afternoon observations in the group home on
9/23/25 revealed client #3 to participate in the
dinner meal. Further observation revealed client
#3 to be furnished with the following adaptive
equipment: wrist weights, large handle spoon,
clothing protector, high sided divided dish and 2
cups with lids and straws, but no non-skid mat.
Continued observation revealed client #3 to
struggle to pick up food during dinner from her
hands shaking.

Morning observations in the group home on
9/24/25 revealed client #3 to participate in the
breakfast meal. Further observation revealed
client #3 to be furnished with the following
adaptive equipment: large handle spoon, clothing
protector, high sided divided dish and 2 cups with
lids and straws, but no non-skid mat and no wrist
weights. Continued observation revealed client #3
to struggle to pick up food and to get her spoon to
her mouth during breakfast due to her hands
shaking.

Review of records on 9/24/25 revealed a PCP for
client #3 dated 9/3/24 which lists client #3's
adaptive equipment as a high sided divided dish,
shirt protector, large handle spoon, non-skid mat,
wrist weights, and a cup with lid and straw.

Interview with the QIDP revealed that client #3's
PCP is current and that the facility should have
made a non-skid mat available for client #3
during both meals and made wrist weights
available during the breakfast meal.

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 | Continued From page 6 W 249

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

Event ID: TMRN11

Facility ID: 924981 If continuation sheet Page 7 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

CFR(s): 483.440(e)(1)

Data relative to accomplishment of the criteria
specified in client individual program plan
objectives must be documented in measurable
terms.

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to ensure data
relative to the accomplishment of objective
criteria was documented in measurable terms.
This affected 5 out of 5 audit clients (#1, #2, #3,
#4 and #5). The findings are:

A. Review on 9/24/25 of client #1's
Person-Centered Plan (PCP) dated 4/9/25
revealed formal training programs as follows:

- Participate in an activity to redirect her from
screaming: Data to be collected daily during first
shift.

- Wipe after using the toilet: Data to be
collected daily on second shift.

- Use the restroom when prompted every two
hours: Data to be collected daily on first shift.

Review on 9/24/25 of client #1's computerized
program data revealed that data was recorded on
only 28 of 116 days between 6/1/25 and 9/24/25.

Interview with the habilitation specialist (HS) and
the qualified intellectual disabilities professional
(QIDP) on 9/24/25 confirmed that the program
data are accurate and that program data has not
been recorded as required.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 7 W 252
W 252 | PROGRAM DOCUMENTATION W 252

Facility ID: 924981

If continuation sheet Page 8 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

SUMMARY STATEMENT OF DEFICIENCIES

(x4) ID

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 10/03/2025

FORM APPROVED

OMB NO. 0938-0391

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

ID PROVIDER'S PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

09/24/2025

(%5)

B. Review on 9/24/25 of client #2's PCP dated
6/16/25 revealed formal training programs as
follows:

- Brush her teeth twice per day: Data to be
collected daily.

- Set the table 3 times per week: Data to be
collected daily on second shift.

- Walk for 20 minutes 3 times per week: Data
to be collected Monday, Wednesday and Friday
on second shift.

Review on 9/24/25 of client #2's computerized
program data revealed that data was recorded on
only 45 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/25
confirmed that the program data are accurate and
that program data has not been recorded as
required.

C. Review on 9/24/25 of client #3's PCP dated
9/13/24 revealed formal training programs as
follows:

- Pull up pants: Data to be collected daily.

- Wash hands after using the restroom: Data to
be collected daily on first shift.

Review on 9/24/25 of client #3's computerized
program data revealed that data was recorded on
only 30 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/25
confirmed that the program data are accurate and
that program data has not been recorded as
required.

D. Review on 9/24/25 of client #4's PCP dated
9/12/25 revealed formal training programs as
follows:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 8 W 252

Facility ID: 924981

If continuation sheet Page 9 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

- Prepare a beverage for the meal: Data to be
collected daily.

- Take trash bag out to the trash can: Data to
be collected daily.

- Walk for 15 minutes: Data to be collected
daily.

Review on 9/24/25 of client #4's computerized
program data revealed that data was recorded on
only 29 of 116 days between 6/1/25 and 9/24/25.

Interview with the HS and the QIDP on 9/24/25
confirmed that the program data are accurate and
that program data has not been recorded as
required.

E. Review on 9/24/25 of client #5's PCP dated
1/10/25 revealed formal training programs as
follows:

- Tolerate sitting in the living room, engaging in
an activity with staff/peers: Data to be collected
daily.

- Use the restroom every two hours when
prompted by staff: Data to be collected daily on
first shift.

- Put dirty clothes in the hamper after bath:
Data to be collected daily on first shift.

- Walk for 15 minutes: Data to be collected
Monday, Wednesday and Friday on second shift.
- Wash hands after toileting: Data to be
collected daily on first shift.

Review on 9/24/25 of client #5's computerized
program data revealed that data was recorded on
only 35 of 116 days between 6/1/25 and 9/24/25.

Further record review revealed in-service training
records from 7/31/25, 8/21/25 and 9/18/25.

However, interviews and data review revealed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 9 W 252

Facility ID: 924981 If continuation sheet Page 10 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

CFR(s): 483.460(k)(2)

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.
This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure medications
were administered in accordance with physician's
orders. This affected 2 client (#2 and #4)
observed during medication administration. The
finding is:

A. The facility failed to ensure that client #4's
medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
client #4 was observed to enter the medication
room at 7:56 AM. Further observation revealed
client #4 to exhibit behaviors including screaming
and throwing items in the medications room. Staff
responded by escorting client #4 to her bedroom
at which time she calmed down. Continued
observation revealed staff A to prepare and
administer the following medications to client #4
Buspirone, CA CIT/Vit D, Senna-Time,
Benztropine, Divalproex, Ferusol, Vit B3, Omega
3 Fish Oil, Levothyroxine, Meloxicam,
Alendronate, Clonidine, Ingrezza, Lactulose.
Continued observation revealed staff A to take the
medications to client #4 in her bedroom and client
#4 to take all medications at 8:05 AM.

Review on 9/24/25 of client #4's physician's
orders dated 9/24/25 revealed that the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 10 W 252
staff are still failing to document data as desribed.
W 369 | DRUG ADMINISTRATION W 369

Facility ID: 924981

If continuation sheet Page 11 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 10/03/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/24/2025

(x4) ID
PREFIX
TAG

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

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

ID
PREFIX
TAG

(8)
COMPLETION
DATE

DEFICIENCY)

W 369 | Continued From page 11

Levothyroxine is to be administered at 6:00 AM
and the Lactulose is to be administered at 5:00
PM.

Interview on 9/27/25 with the nursing supervisor
confirmed that client #4's Levothyroxine and
Lactulose were administered outside of the time
prescribed for each and that all medications
should be administered according to the
physicians' orders.

B. The facility failed to ensure that client #2's
medications were administered at the correct
time. For example:

During observations in the home on 9/24/25,
client #2 was observed to enter the medication
room at 8:15 AM. Further observation revealed
staff A to prepare and administer the following
medications to client #2: Lorazepam, Omega 3
Fish Oil, Cetirizine, Duloxetine, Vit D3, Lo
Loestrine, Ciclopirox. Continued observation
revealed client #2 to take all medications at 8:20
AM.

Review on 9/24/25 of client #2's physician's
orders dated 7/15/25 revealed that all
medications are to be administered at 7:00 AM.

Interview on 9/27/25 with the nursing supervisor
confirmed that all of client #2's medications
should have been administered between 6:00 AM
and 8:00 AM and that all medications should be
administered according to the physicians' orders.
DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(1)(2)

W 382

The facility must keep all drugs and biologicals

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

W 369

W 382

Facility ID: 924981

If continuation sheet Page 12 of 13

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/03/2025

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PROVIDER'S PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

09/24/2025

locked except when being prepared for
administration.

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure all medications and biologicals
remained locked except when being prepared for
administration. The finding is:

Morning observations in the home on 9/24/25 at
8:03 AM revealed staff A to leave the medication
area and leave 14 medications, including 1
controlled medication, on a desk. Further
observations revealed that there is no door on the
medication room, just a privacy screen which is
pulled across the door when clients are in the
room. Continued observations revealed all staff
to be away from the medication room for 5
minutes with the medications out on the desk.

Interview on 9/24/25 with the nursing supervisor
revealed that all medications should be locked
inside the medication cart when staff are not
directly supervising the medications.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TMRN11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 382 | Continued From page 12 W 382

Facility ID: 924981

If continuation sheet Page 13 of 13

document_type: Statement of deficiency


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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 07/21/2025

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

(X3) DATE SURVEY

COMPLETED

R-C
07/21/2025

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 000} | INITIAL COMMENTS {W 000}
Arevisit was conducted on 7/21/2025 for all
previous deficiencies cited on 5/22/2025. All
deficiencies were corrected and no new
non-compliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

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

Event ID: ICMF12

Facility ID: 924981

If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Complaint

raw_content:
PRINTED: 05/27/2025
FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
COMPLETED

Cc
346303 BWW 05/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
MONROE ROAD CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION | (85)

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

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

NAME OF PROVIDER OR SUPPLIER

SUMMARY STATEMENT OF DEFICIENCIES 10

(Xa) 10
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE OATE
DEFICIENCY)
y T 7
W 000 | INITIAL COMMENTS W000

A complaint survey was completed on May 22,
2025 for intake #NC00229511. The allegation

| was substantiated and deficiencies were cited
Additional deficiences were cited not related to
the allegation in the areas of dietetic services and
active treatment

DIRECT CARE STAFF w
had FR pe tet "87 W187: The IDD Adminstrator will
re-service the Qualified Profession |
| al, Direct Support Supervisor and
all staff remain adaquate. The
clinical team members(IDD Admin
strator, Nursing staff, Hab Spec & |
other adminstrative staff) will

Direct care staff must be provided by the facility in
the following minimum ratios of direct care staff to

clients.
(i) For each defined residential living unit serving |
children under the age of 12, severely and

profoundly retarded clients, clients with severe conduct random phone and or vis
physical disabilities, or clients who are ual checks at least twice per week.
aggressive, assaultive, or security risks, or who | The QP will develop an emergency
manifest severely hyperactive or psychotic-like back-up plan for DSP staffing that |
behavior, the staff to client ratio is 1 to 3.2; | arise at the facility. The back-up

(ii) For each defined residential living unit | staff will be provided.

serving moderately retarded clients, the staff to
client ratio is 1 to 4;

(iii) For each defined residential living unit
serving clients who function within the range of | |
mild retardation, the staff to client ratio is 1 to 6 4.
This STANDARD is not met as evidenced by
Based on record review and interviews, the
facility failed to ensure adequate staff-to-client
ratios were met for 6 of 6 clients in the facility.
The finding is:

Review of the client records on 5/22/25 revealed
four of five clients in the facility have a moderate |
or severe I/DD diagnosis, Review of clients

records also revealed one client having an |
intermittent explosive disorder diagnosis. Further
review of clients records revealed three clients | |

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

TIME (6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or nota plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the data thése documosts are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation
oe 1 ' =D A A, ‘of /AL— 2G IAS

FORM CMS-2567(02-99) Previous Versions Obsole Event ID: ICM 11 Facility 10. 924981 continuation sheet Page 1 of §

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

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

(<1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER.

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

346303

(X2) MULTIPLE CONSTRUCTION
A BUILDING

8. WING

(X3) DATE SURVEY
COMPLETED

c
05/22/2025

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

STREET ADDRESS, CITY, STATE, 2iP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PROVIDER'S PLAN OF CORRECTION | 8)

having gait concerns which require the need for
adaptive equipment (i.e. gait belt) and staff
assistance.

Review of the employee timesheet and employee
staffing schedule from 3/1/25-5/22/25 revealed
that on multiple dates there was no
documentation to verify that at least 2 direct care
staff were working on first or second shift in the
facility. Further review of timesheets and staff
scheduling could not reveal if more than one staff
| worked on first and second shifts during multiple
weekends between 4/1/25-5/20/25. Review of the
timesheets and staff schedule could not verify if
staff coverage was sufficient on multiple dates (6)
in 4/2025 and 5/2025.

Interview with staff A on 5/22/25 revealed she has
worked double shifts daily on first and second
Shifts for at least a month. Further interview with
staff A revealed she has worked alone with six
clients over the past month.

Interview with staff B on 5/22/25 revealed she
works alone and is a full time staff on third shift
Further interview with staff B revealed she works
alone with the six clients, although occasionally
another third shift staff will come in to assist with
| clients waking schedule and personal care.

The facility administrator was not available on
§/22/25 for interview during the complaint survey
The interim qualified intellectual disabilities
professional (QIDP) on site on 5/22/25 was not
the primary QIDP and could not answer questions
| relative to staff scheduling and staff coverage
Interview with the interim QIDP revealed that
Staffing should be appropriate based on the
clients’ needs.

(%4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENGED TO THE APPROPRIATE oate
| DEFICIENCY)
i
|
W 187 | Continued From page 1 Ww 187 |

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

Event IDICMF It

Facility ID. 924981 If continuation sheet Page 2 of 5

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

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

00) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES
IDENTIFICATION NUMBER

AND PLAN OF CORRECTION

346303

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

SUMMARY STATEMENT OF DEFICIENCIES

x4) ID
Fer (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
{
W249 PROGRAM IMPLEMENTATION

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

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

|
| This STANDARD is not met as evidenced by

| Based on observations, record reviews and

| interviews, the facility failed to ensure 1 of 5 audit
Clients (#2) received a continuous active
treatment program as identified in their behavior
| Support plan (BSP). The finding is

| Observation in the group home on 5/22/25 from
7:28 AM - 8:00 AM revealed client #2 to sit in the
| living room, yelling racial slurs and obscenities.
Continued observations revealed staff A to take a
deep breath and turn away without redirecting the
client. Further observations revealed the newly
hired home manager at 7:50 AM to occasionally
say to the client, “that's not nice".

Review of client #2 record on 5/22/25 revealed a
behavior support plan (BSP) dated 3/1/24
Continued review of the BSP revealed the

| following targeted behaviors: aggressive
behavior, loud yelling; digging in undergarments;
taking food-going into the kitchen, pantry, freezer,
| or refrigerator and taking or eating food not

| belonging to her.

Further review of client #2's BSP interventions

(2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY

EOE COMPLETED
Cc
Bi aaa 05/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
iD PROVIDER'S PLAN OF CORRECTION 8)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE. | COMPLETION
TAG CROSS-REFERENCED 10 THE APPROPRIATE | OaTE

DEFICIENCY)

——|

W 249:Direct Support Professionals |
will be inserviced on continuous
active treatment regarding the
behavior support plan in re-direct
jion to an activity and to utilize
appropriate verbalization. |

W249

FORM CMS-2567(02-98) Previous Versions Obsolete Event 1D:ICMF 11

Facility ID. 924981 If continuation sheet Page 3 of §

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X41) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346303

8. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

Cc
05/22/2025

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

STREET ADDRESS, CITY, STATE, 21? CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(x4) ID
PREFIX
TAG

W249

W 473

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

PROVIDER'S PLAN OF CORRECTION

Continued From page 3

relative to loud yelling indicated when the client

| makes inappropriate or loud comments, "staff
should redirect her to an activity while verbalizing
what activity you will be engaging in (i.e. let's read
| a book). Encourage her to repeat the activity you
mentioned. The idea is attempting to redirect her
to more appropriate verbalizations. Staff should

| praise her for engagement in an activity without
inappropriate comments. Staff should remind her
| that the words she is saying are "not nice" and

| offer other statements for her to repeat that "are

| nice". Praise her when she makes appropriate
comments and encourage her to say them
again”

Interview with the interim qualified intellectual
developmental professional (QIDP) on 5/22/25
| verified staff did not follow the BSP as prescribed
| MEAL SERVICES
| CFR(s): 483.480(b)(2)(ii)

Food must be served at appropriate temperature.

This STANDARD is not met as evidenced by:

| Based on observation and interview, the facility

| failed to ensure food was served at an

appropriate temperature for 4 of 4 sampled
clients (#1, #2, #4, and #5). The finding is:

|
| Morning observations in the facility on 5/22/25 at
| 7:00 AM revealed the dining table fully set and

| breakfast served in clients #1, #2, #4 and #5
plates. Further observations revealed the

, breakfast meal to consist of scrambled eggs,
toast Cut into pieces, slices of banana and
tangerine pieces. Continued observation between
| 7:25 AM and 7:30 AM revealed all clients to sit at
the dining table and consume their breakfast

| meal. Subsequent observations revealed the

FORM CMS-2557(02-99) Provious Versions Obsolete

Event ID:ICMF 1

10
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG | CROSS-REF ERENCED TO THE APPROPRIATE oate
| DEFICIENCY)
T
| |
W249} |
|
|
| |
|
| | |
|
|
|
|
| |
|
|
|
| |
|
| |
| | |
W473) W473: Direct Support Professional

and Direct Support Supervisor will |
be inserviced on appropriate
temperature of food when being
served and coverage of food.

Facilty 10. 924981

' continuation sheet Page 4 of 5

PRINTED: 05/27/2025
FORM APPROVED
OMB NO_ 0938-0391

(X3) DATE SURVEY

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ABUIEDING COMPLETED
Cc
346303 BVANG 05/22/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
oF ROAD 7621 MONROE ROAD
MONROE ROA
CHARLOTTE, NC 28212
(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE Dare
| | DEFICIENCY) |
| | |
W 473 | Continued From page 4 W473

breakfast plates to sit at the table uncovered for |
| 30 minutes. Additional observations did not reveal
staff to cover or offer to warm clients #1, #2, #4
| and #5 scrambled eggs.
|

Interview with the facility interim qualified |
intellectual disabilities professional (QIDP) on
§/22/25 revealed all meals should be served at an
appropriate temperature prior to serving the
clients. |

|
| |
| | |
|

| |
Facility 1D 924981 If continuation sheet Page 5 of §

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID.ICMF 11

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Complaint

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 05/27/2025

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

c
05/22/2025

(8)
COMPLETION
DATE

W 000 | INITIAL COMMENTS

A complaint survey was completed on May 22,
2025 for intake #NC00229511. The allegation
was substantiated and deficiencies were cited.
Additional deficiences were cited not related to
the allegation in the areas of dietetic services and
active treatment.

W 187 | DIRECT CARE STAFF

CFR(s): 483.430(d)(3)

Direct care staff must be provided by the facility in
the following minimum ratios of direct care staff to
clients:

(i) For each defined residential living unit serving
children under the age of 12, severely and
profoundly retarded clients, clients with severe
physical disabilities, or clients who are
aggressive, assaultive, or security risks, or who
manifest severely hyperactive or psychotic-like
behavior, the staff to client ratio is 1 to 3.2;

(ii) For each defined residential living unit
serving moderately retarded clients, the staff to
client ratio is 1 to 4;

(iii) For each defined residential living unit
serving clients who function within the range of

This STANDARD is not met as evidenced by:
Based on record review and interviews, the
facility failed to ensure adequate staff-to-client
ratios were met for 6 of 6 clients in the facility.
The finding is:

Review of the client records on 5/22/25 revealed
four of five clients in the facility have a moderate
or severe I/DD diagnosis. Review of clients
records also revealed one client having an
intermittent explosive disorder diagnosis. Further
review of clients records revealed three clients

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

mild retardation, the staff to client ratio is 1 to 6.4.

W 000

W 187

TITLE

(X6) DATE

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

program participation.

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

Event ID: ICMF11

Facility ID: 924981 If continuation sheet Page 1 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
05/22/2025

having gait concerns which require the need for
adaptive equipment (i.e. gait belt) and staff
assistance.

Review of the employee timesheet and employee
staffing schedule from 3/1/25-5/22/25 revealed
that on multiple dates there was no
documentation to verify that at least 2 direct care
staff were working on first or second shift in the
facility. Further review of timesheets and staff
scheduling could not reveal if more than one staff
worked on first and second shifts during multiple
weekends between 4/1/25-5/20/25. Review of the
timesheets and staff schedule could not verify if
staff coverage was sufficient on multiple dates (6)
in 4/2025 and 5/2025.

Interview with staff A on 5/22/25 revealed she has
worked double shifts daily on first and second
shifts for at least a month. Further interview with
staff A revealed she has worked alone with six
clients over the past month.

Interview with staff B on 5/22/25 revealed she
works alone and is a full time staff on third shift.
Further interview with staff B revealed she works
alone with the six clients, although occasionally
another third shift staff will come in to assist with
clients waking schedule and personal care.

The facility administrator was not available on
5/22/25 for interview during the complaint survey.
The interim qualified intellectual disabilities
professional (QIDP) on site on 5/22/25 was not
the primary QIDP and could not answer questions
relative to staff scheduling and staff coverage.
Interview with the interim QIDP revealed that
staffing should be appropriate based on the
clients’ needs.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ICMF11

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 187 | Continued From page 1 W 187

If continuation sheet Page 2 of 5

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

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

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 05/22/2025

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

MONROE ROAD
CHARLOTTE, NC 28212

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

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

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to ensure 1 of 5 audit
clients (#2) received a continuous active
treatment program as identified in their behavior
support plan (BSP). The finding is:

Observation in the group home on 5/22/25 from
7:28 AM - 8:00 AM revealed client #2 to sit in the
living room, yelling racial slurs and obscenities.
Continued observations revealed staff A to take a
deep breath and turn away without redirecting the
client. Further observations revealed the newly
hired home manager at 7:50 AM to occasionally
say to the client, "that's not nice".

Review of client #2 record on 5/22/25 revealed a
behavior support plan (BSP) dated 3/1/24.
Continued review of the BSP revealed the
following targeted behaviors: aggressive
behavior; loud yelling; digging in undergarments;
taking food-going into the kitchen, pantry, freezer,
or refrigerator and taking or eating food not
belonging to her.

Further review of client #2's BSP interventions

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ICMF11

Facility ID: 924981

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

If continuation sheet Page 3 of 5

PRINTED: 05/27/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

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

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346303 05/22/2025

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

7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

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

PROVIDER'S PLAN OF CORRECTION (x5)

(x4) ID
PREFIX
TAG

COMPLETION
DATE

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

DEFICIENCY)

W 249 | Continued From page 3

relative to loud yelling indicated when the client
makes inappropriate or loud comments, "staff
should redirect her to an activity while verbalizing
what activity you will be engaging in (i.e. let's read
a book). Encourage her to repeat the activity you
mentioned. The idea is attempting to redirect her
to more appropriate verbalizations. Staff should
praise her for engagement in an activity without
inappropriate comments. Staff should remind her
that the words she is saying are "not nice" and
offer other statements for her to repeat that "are
nice". Praise her when she makes appropriate
comments and encourage her to say them
again".

Interview with the interim qualified intellectual
developmental professional (QIDP) on 5/22/25
verified staff did not follow the BSP as prescribed.
MEAL SERVICES

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

W 473

Food must be served at appropriate temperature.
This STANDARD is not met as evidenced by:
Based on observation and interview, the facility
failed to ensure food was served at an
appropriate temperature for 4 of 4 sampled
clients (#1, #2, #4, and #5). The finding is:

Morning observations in the facility on 5/22/25 at
7:00 AM revealed the dining table fully set and
breakfast served in clients #1, #2, #4 and #5
plates. Further observations revealed the
breakfast meal to consist of scrambled eggs,
toast cut into pieces, slices of banana and
tangerine pieces. Continued observation between
7:25 AM and 7:30 AM revealed all clients to sit at
the dining table and consume their breakfast
meal. Subsequent observations revealed the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ICMF11

W 249

W 473

Facility ID: 924981

If continuation sheet Page 4 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 05/27/2025

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

(X3) DATE SURVEY

COMPLETED

c
05/22/2025

breakfast plates to sit at the table uncovered for
30 minutes. Additional observations did not reveal
staff to cover or offer to warm clients #1, #2, #4
and #5 scrambled eggs.

Interview with the facility interim qualified
intellectual disabilities professional (QIDP) on
5/22/25 revealed all meals should be served at an
appropriate temperature prior to serving the
clients.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ICMF11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 473 | Continued From page 4 W 473

Facility ID: 924981

If continuation sheet Page 5 of 5