raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 06/26/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 118)

INITIAL COMMENTS

Acomplaint survey was completed on June 21,
2024. The complaint was substantiated (intake
#NC00216650). A deficiency was cited.

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

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

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

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

Division of Health Service Regulation

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

STATE FORM

V 000

V 118

6899

PKHK11

TITLE

(X6) DATE

If continuation sheet 1 of 7

Division of Health Service Regulation

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

MHL004-016

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 Vv 118

(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to administer medication as ordered
by a person authorized by law to prescribe drugs
affecting 1 of 3 audited clients (#1). The findings
are:

Review on 6/19/24 of client #1's record revealed:
-Admission date of: 7/19/23.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Posttraumatic Stress Disorder,
Attention

Deficit Hyperactivity Disorder, Nocturnal Enuresis,
Child Physical Abuse, Child Neglect, and Child
Sexual Abuse.

Review on 6/19/24 of client #1's signed physician
order dated 7/21/23.

-Propranolol (anxiety) 20mg (milligrams) Give 2
tablets by mouth daily every morning. Give 2
tablets by mouth daily at 4:00 pm. Give 4 tablets
by mouth daily at bedtime.

Review on 6/21/24 of facility incident reported
dated 4/19/24 revealed:

-"[Client #1] takes 2 Propranolol tablets at
8:00am, 2 Propranolol tablets at 4:00 pm and 4

Division of Health Service Regulation
STATE FORM

6809

PKHK11

If continuation sheet 2 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

Propranolol tablets at 8:00 pm. When 8:00 am
medications were given [Client #1] did not have
available her 2 tablets of Propranolol doses to be
able to administer from pharmacy. At
approximately 10:00 am the medications that
were received from am delivery were checked in
and [Client#1's] Propranolol refill had arrived,
[Registered Nurse (RN)] placed 8:00 am dose of
2 tablets in with [Client #1] 4:00 pm dose of 2
tablets to give proper daily does of 8 tablets."

Interview on 6/19/24 with client #1 revealed:

-"| got two extra pills when | went on an outing to
the Aquarium."

-"| don't remember who gave me the pills that
day."

-"[RN] makes the bag of pills and gives it to the
staff."

-"| was supposed to have five pills instead of
seven pills in the bag."

"| told [Staff #1] that it was too many blue pills,
and the white pills were right."

-"[Staff #1] told me to take the pills because the
nurse wasn't there."

-"This was the first time this ever happened to
me."

-"| did not get sick from taking the extra
medication."

-"| remember telling the staff that was on the van
and the staff when we got back to the facility that |
had taken too many pills."

Interview on 6/20/24 with the Facility RN
revealed:

-"[Client #1's] 8:00 am dosage of Propranolol
wasn't available for the medication (med) pass
due to the pharmacy running late on April 19,
2024.

-She received the medication right before [Client
#1] had left to go out on the outing.

Division of Health Service Regulation

STATE FORM

6809

PKHK11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 2 Vv 118

If continuation sheet 3 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

-"| had packaged a total of 7 pills with the two
extra pills that [Client #1] had missed that
morning."

- "If [Client #1] doesn't get the correct dosage it
will trigger [Client #1] into a psychotic episode."
-"[Client #1] will start having anxiety which will
lead into uncontrollable behaviors."

-Client #1 got a total of eight pills of Propranolol
per day with two in the morning, two in the
afternoon, and four at night.

-| couldn't discuss the changes in [Client #1's]
medication to staff or [Client #1] because they
were already on the van.

-"| documented the extra dosage that was given
to [Client #1] on back of the MAR, wrote an
incident report, and wrote a nurses note."

-"| did not notify the doctor that | had given [Client
#1] a different dosage at 4:00 pm med pass." "I
didn't know | had to notify the doctor to give an
extra dose at a different time."

-"| didn't think it was a problem giving [Client #1]
an extra dose of Propranolol because client #1
takes four pills at night."

-Client #1 didn't had any ill effects from taking an
extra dose at 4:00 pm.

-"[Client #1] and the [Executive Director] came to
see me after they got back from the outing with
the concern of [Client #1's] taking too much
medication."

-"[Client #1] told me that she took too many pills
during [Client #1] med pass while on the outing."
-"[Client #1] said that she was only supposed to
take five pills and took seven pills."

-"| explained to [Client #1] and the [Executive
Director] that the two extra pills were the pills
[Client #1] missed at 8:00 am med pass."
-"During the 8:00 am med pass the pills weren't
available due to the pharmacy running late."
-When the pills had gotten to the facility, |
packaged the pills up, and gave them to staff

Division of Health Service Regulation

STATE FORM

6809

PKHK11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 3 Vv 118

If continuation sheet 4 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

while they were on the van.

-"| told [Client #1] that | didn't have time to explain
the extra two pills in the package."

-"[Client #1] said ‘okay’, and didn't have any other
questions."

-"| think | told [Dr. Wilson] about the incident on
Tuesday when we had our weekly meeting but |
didn't document it."

Interview on 6/19/24 with Staff #1 revealed:
-When going on a long outing the nurse would
package the client's medication in a bag with the
date, initials, and time the medication are
administered.

-"[Administrative Assistant] told me to give [Client
#1] and [Client #6] their medication at 4:00 pm."
-"| don't remember how many pills were in the
bag because the pills were already bagged up."
-"| gave [Client #1] and [Client #2] a drink to take
with their medications and watched them swallow
the pills."

-"[Client #1] had taken the pills with no problems
and did not have an ill effect from the
medication."

-"[Client #1] was talking to [Staff #2], saying that
he took too many pills while on the back of the
van."

-"Staff don't count the medication, just give the
client what's in the bag that is prepared by the
nurse."

-"[Client #1] was acting normal and didn't have
any ill effects after taking the medication."

-She had been trained on medication
administration.

Interview on 6/19/24 with the Executive Director
revealed:

-"When [Client #1] had gotten back from the
outing, [Client #1] told me that there were seven
pills in the zip lock bag, and it was only supposed

Division of Health Service Regulation

STATE FORM

6809

PKHK11

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

If continuation sheet 5 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
06/21/2024

to five pills in the zip lock bag."

-"[Client #1] said that she took all seven pills that
were in the zip lock bag."

-"| asked [Client #1] why she took all seven pills
knowing [Client #1] was only supposed to take
five pills?"

-"[Client #1] told me that she took the pills
because [Client #1] didn't want the [RN], to be
mad at her."

-"The [RN] will pack the medication in a zip lock
bag with the client's initials and the time
medication is supposed to be administered."
-Staff would have a bottle of water and watched
the clients take their medication.

-"[Client #1] had come back from the outing
telling me that staff gave her too much
medication."

-"| had taken [Client #1] to the nurse to inquire
about the medication [Client #1] had taken while
on the outing.

-"The [RN] explained to [Client #1] that she
missed her 8:00 am medication due to being
delivered late."

-"The [RN] informed [Client #1] the [RN]
packaged an extra 2 pills to give to her at 4:00
pm to make sure [Client #1] doesn't miss any
medication."

-"[Client #1] understood everything the [RN] told
her about the medication and had no ill effects."
-"| was not aware of the nurse notifying the doctor
of giving [Client #1] an extra dosage at 4:00 pm
medication pass."

Interview on 6/21/24 with the Director of
Operations revealed:

-"| wasn't aware that [Client #1] had taken two
extra pills during her 4:00 pm dosing while on an
outing in April 2024."

-"| was later told by the [Executive Director] that
[Client #1] had taken two extra pills while on the

Division of Health Service Regulation

STATE FORM

6809

PKHK11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 5 Vv 118

If continuation sheet 6 of 7

PRINTED: 06/26/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 6 Vv 118

outing."

-"The RN packages the client's medication, the
medication is given to staff, and staff administers
the medication to the clients."

-"| don't know anything about the medication due
to being prepackaged by the nurse.”

-"| think the doctor was notified of the incident on
Tuesday during their weekly meeting.

-"| will make sure the nurse notifies Dr. Wilson
before giving any extra pills to ensure
compliance."

-"The [RN] had written a note and incident report
regarding the incident."

Division of Health Service Regulation
STATE FORM

6809

PKHK11

If continuation sheet 7 of 7


state: NC

facility_name: Cornerstone Treatment Facility

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

raw_content:
PRINTED: 05/02/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 TT 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000} INITIAL COMMENTS Vv 000

A complaint and follow up survey was completed
on April 24, 2024. The complaints were
substantiated (intake #NC00215448 and
#NC00215686). Deficiencies were cited.

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

The facility is licensed for 12 and currently has a
census of 12. The survey sample consisted of
audits of 5 current clients.

V 314) 27G .1901 Psych Res. Tx. Facility - Scope V 314

10A NCAC 27G .1901 SCOPE

(a) The rules in this Section apply to psychiatric
residential treatment facilities (PRTF)s.

(b) APRTF is one that provides care for children
or adolescents who have mental illness or
substance abuse/dependency in a non-acute
inpatient setting.

(c) The PRTF shall provide a structured living
environment for children or adolescents who do
not meet criteria for acute inpatient care, but do
require supervision and specialized interventions
on a 24-hour basis.

(d) Therapeutic interventions shall address
functional deficits associated with the child or
adolescent's diagnosis and include psychiatric
treatment and specialized substance abuse and
mental health therapeutic care. These
therapeutic interventions and services shall be
designed to address the treatment needs
necessary to facilitate a move to a less intensive
community setting.

(e) The PRTF shall serve children or adolescents
for whom removal from home or a

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

STATE FORM 6609 uGoI1 If continuation sheet 1 of 17

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024
FORM APPROVED

(X3) DATE SURVEY

community-based residential setting is essential
to facilitate treatment.

(f) The PRTF shall coordinate with other
individuals and agencies within the child or
adolescent's catchment area.

(g) The PRTF shall be accredited through one of
the following; Joint Commission on Accreditation
of Healthcare Organizations; the Commission on
Accreditation of Rehabilitation Facilities; the
Council on. Accreditation or other national
accrediting bodies as set forth in the Division of
Medical Assistance Clinical Policy Number 8D-1,
Psychiatric Residential Treatment Facility,
including subsequent amendments and editions.
A copy of Clinical Policy Number 8D-1 is available
at no cost from the Division of Medical Assistance
website at http://www.dhhs.state.nc.us/dma/.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to coordinate client care with other
individuals and agencies affecting one of five
clients (#1). The findings are:

Review on 4/9/24 of client #1's record revealed:
-Admission date of 9/5/23.

-Diagnoses of Post Traumatic Stress Disorder
Chronic; Attention Deficit Hyperactivity Disorder;
and Predominantly Inattentive Type.

-15 years old.

Division of Health Service Regulation
STATE FORM

6809

UGOI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 314] Continued From page 1 V 314

If continuation sheet 2 of 17

Division of Health Service Regulation

PRINTED: 05/02/2024
FORM APPROVED

Review on 4/9/24 of a facility incident report dated
3/26/24 revealed:

-The RN observed client #1 run into the
bathroom. "[Staff #6], [staff #7], and [RN] entered
the bathroom where [client #1] was sitting on the
floor crying saying to just leave [client #1] alone."
[Staff #6], [staff #7], and [RN] processed with
[client #1], [client #1] stood up and excited
bathroom going out into residential hallway and
trying to enter community area, but path was
obstructed by [Executive Director]." "[Client #1]
turned and entered into [client #1's] room, [staff
#6), [staff #7], and [RN] again processed with
[client #1] in efforts to clam her down, however,
processing failed and client #1] tried pushing staff
to gain access to residential hallway, for the
safety of client, staff and peers, staff continued to
block [client #1's] path causing her to become
increasingly aggressive both physically and
verbally." "[Staff #6 turned her back to exit room,
[client #1] jumped from her bed to the back of
[staff #6] and began pulling her hair, snatching
out the hair from her scalp and hitting [staff #6]."
"[Client #1] began to yell at [staff #6] you hurt
me." [Client #1] said that [staff #6] choked [client
#1] and triggered [client #1]." "[Staff #6] told
[client #1] that [staff #6] did not hit or choke client
#1.

Interview on 4/10/24 with the Department of
Social Services's (DSS) Guardian for client #1
revealed:

-"[Qualified Professional (QP)] apologized to me
for not telling me about the incident that
happened with [client #1]."

-"[QP] was under the impression that the [Vice
President of Operations] was supposed to call the
guardian."

-"[QP] told me that the [Vice President of
Operations] completes the incident reports and

Division of Health Service Regulation

STATE FORM

6808 UGOI11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 314] Continued From page 2 V 314

If continuation sheet 3 of 17

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/24/2024

makes the calls to everyone involved."

-"| was notified by local County DSS yesterday
(4/9/24) of the incident that they are currently
investigating."

-"The [QP] sent me the incident report yesterday
on 4/9/24."

-"| did a family and friends visit last week, and
[client #1] nor the staff told me about the
incident."

Interview on 4/18/24 with the QP revealed:

-"The guardian called me and told me that she
was notified by local County DSS regarding the
incident with [client #1]."

-Vice President of Operations notified the
guardian when there are allegations.

-"[Vice President of Operations] notifies the local
county Department of Social Services (DSS), the
State, but not sure if Disability Rights, and Health
Care Personnel Registry (HCPR) were notified."
-"| knew that the guardian wasn't notified when
she called me to talk about the incident with
[client #1]."

-"| apologized to the guardian for not notifying her
about the incident and that was messed up."
-She assumed that the Vice President of
Operation contacted the guardian when she
completed the Incident Response Improvement
System (IRIS) report online.

-"| would have notified the guardian if | would
have known she wasn't notified."

-"The ball got dropped."

Interview on 4/9/24 with the Executive Director
revealed:

-She remembered that an incident report was
written, Child Protective Services (CPS) and DSS
were notified of the incident.

-"| wasn't sure if HCPR or the guardian was
notified."

Division of Health Service Regulation
STATE FORM

6809

UGOI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 314] Continued From page 3 V 314

If continuation sheet 4 of 17

PRINTED: 05/02/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 314] Continued From page 4 V 314
Interview on 4/15/24 with the Director of
Operations revealed:
-He was not aware that client #1's guardian
wasn't notified of the incident.
-"| thought [Vice President of Operations] had
contacted the guardian after she completed the
incident report in IRIS."
-"Management has produced a form where it will
show when guardian was notified and by whom."
V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect V 512

10A NCAC 27D .0304 PROTECTION FROM
HARM, ABUSE, NEGLECT OR EXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.

(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10A NCAC
27C .0102 of this Chapter.

(c) Goods or services shall not be sold to or
purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation by an employee of Paragraphs
(a) through (d) of this Rule shall be grounds for
dismissal of the employee.

Division of Health Service Regulation
STATE FORM

e899 uGoI11 If continuation sheet 5 of 17

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024
FORM APPROVED

(X3) DATE SURVEY

This Rule is not met as evidenced by:

Based on record reviews and interviews, one of
five audited staff (#6) abused one of five current
audited client (#1). The findings are:

Review on 4/9/24 of Staff #6's record revealed:
-Date of hire: 8/27/2018.

Review on 4/9//24 of client's #1 record revealed:
-Admission date of 9/5/23.

-Diagnoses of Post Traumatic Stress Disorder
Chronic; Attention Deficit Hyperactivity Disorder;
and Predominantly Inattentive Type.

-She was 15 years old.

-Assessment dated 9/8/23 had the following: "She
(client #1) has a history of struggling with
impulsively, lying, stealing, and not following
rules. She is assaultive and has violent behavior
towards peers and adults."

Review on 4/9/24 of a facility incident report dated
3/26/24 revealed:

-"[Registered Nurse (RN)] reported to hallway to
observe [client #1] run into the bathroom. "[Staff
#6], [staff #7] and [RN]entered into bathroom
where [client #1] was sitting on floor crying saying
to just leave her alone." "[Staff #6], [Staff #7], and
[RN] processed with [client #1] telling [client #1]
that she would have to exit bathroom but [client
#1] refused staff directions." [RN], [staff #6], [staff
#7] processed with [client #1], [client #1] stood up
and exited bathroom going into residential
hallway and trying to enter community area, but
path was obstructed by staff." [Client #1] turned
and entered into her room. [RN], [staff #6] and
[staff #7] again processed with [client #1] in
efforts to calm [client #1] down, however
processing failed and [client #1] tried pushing

Division of Health Service Regulation

STATE FORM

6809

UGOI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 5 V 512

If continuation sheet 6 of 17

Division of Health Service Regulation

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

MHL004-016

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 05/02/2024

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

CORNERSTONE TREATMENT FACILITY

WADESBORO, NC 28170

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/24/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 6 V 512

staff to gain access to residential hallway, for the
safety of [client #1], staff and peers staff
continued to block [client #1] path causing her to
become increasingly aggressive both physically
and verbally. [Client #1's] bedroom door was
closed to prevent [client #1] from running out of
her room into hallway. [Client #1] began swinging
and hitting staff to exit her room was not able to
bypass staff. After approximately 20 minutes it
had seemed that [client #1] was entering
De-escalation. As [staff #6] turned her back to
exit room, [client #1] jumped from her bed to the
back of [staff #6] and began pulling [staff #6] hair,
snatching out the hair from [staff #6] scalp and
hitting [staff #6]. [Client #1] began to yell at [staff
#6] you hurt me. You choked me and triggered
me. [Staff #6] told [client #1] that [staff #6] did not
hit or choke [client #1]. [Staff #6] exited [client
#1's] room leaving [RN] and [staff #7] in room
with [client #1]. [Client #1] became very emotional
crying to [RN] and [staff #7] saying 'l am sorry but
when [staff #6] choked [client #1] it triggered me
because she hurt me.' [RN] informed [client #1]
that [RN] did not see [staff #6] choke or hit [client
#1] but incident would be reported to Executive
Director/Administrator including RN's statement in
incident report. No injuries visualized by [RN]. No
medical intervention needed at this time."

Interviews regarding the 3/26/24 incident with
client #1:

Interview on 4/9/24 with client #4 revealed:

-"| didn't see it but | heard the whole thing
because | was in the room next door."

-"It was a lot of bumping in the room and very
chaotic."

-"[Staff #6] was coming out the room with [staff
#6's] shirt was halfway up showing her stomach."
-All the other clients were down the hall.

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 7 of 17

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170

PRINTED: 05/02/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/24/2024

Interview on 4/15/24 and 4/23/24 with staff #7
revealed:

-"[Staff #6] and [RN] called me because [client
#1] would not come out of the bathroom."
-"When | had gotten to the bathroom, [RN] and
[staff #6] were in the bathroom trying to calm
[client #1] down."

-Client #1 refused to leave the bathroom.

-"Me and [staff #6] did a CPI restraint (Crisis
Prevention Institute) to get [client #1] out the
bathroom."

-"We were on both sides of [client #1] with our
hands over [client #1's] fist so she wouldn't swing
and held [client #1's] arms by her side."

-"Once we got [client #1] out the bathroom, we let
her go."

-Client #1 ran into client #4's bedroom.

-"Me and [staff #6] were trying to calm [client #1]
down so she could leave [client #4's] bedroom,
but she refused."

-"Me and [Staff #6] did another CPI restraint the
same way to get [client #1] out [client #4's]
bedroom and took [client #1] to her bedroom."
-"Once we got to [client #1's] bedroom, | let her
arm go because the three of us couldn't fit
through the door."

-"Once [client #1] was in the room, [staff #6]
pushed [client #1] up against the wall with her
forearm up against [client #1's] neck."

-Client #1 and staff #6 fell on the bed.

-"| saw [client #1] grip [staff #6's] shirt while they
were on the bed."

-"[Staff #8] and | tried to stop [client #1] from
ripping [staff #6's] shirt."

-"We had gotten [client #1's] hands loose from
gripping [staff #6's] shirt and [staff #6] had gotten
up from the bed."

-"[Client #1] jumped up and punched [staff #6] in
the back of her head."

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 7 V 512

If continuation sheet 8 of 17

Division of Health Service Regulation

PRINTED: 05/02/2024

FORM APPROVED

-"After [client #1] punched [staff #6], they both
started fighting each other."

-"[Client #1] and [staff #6] were punching each
other."

-Staff #8 and | broke up the fight between client
#1 and staff #6.

-The RN had come back into the bedroom to
escort staff #6 out of the bedroom.

-After the RN escorted staff #6 out of the room,
the RN come back to check on client #1.

-"| don't know if they told management about the
incident."

-"| don't remember if | told [Executive Director]
about [client #1] and [staff #6] fighting each
other."

-Management hasn't done any new training since
the incident happened.

Interview on 4/11/24 and 4/23/24 with staff #8
revealed:

-"| was just getting back from getting something
to eat and [client #1] was yelling get off me in
[client #4's] bedroom."

-"[Staff #6] was holding [client #1] from the back
in a bear hug."

-Staff #6 and staff #7 took client #1 out of client
#4's bedroom to client #1's bedroom.

-"[Staff #7] was holding [client #1's] feet while
[staff #6] had [client #1's] upper body."

-Client #1 was kicking and screaming while being
taken to her bedroom.

-"[Staff #6] was still holding [client #1] from the
back while standing by the window when | walked
in the bedroom."

-"| heard [client #1] say that [staff #6] is the only
staff that restrain them like that."

-"[Staff #6] was telling [client #1] that she can't
fight anyways."

-Staff #6 had let client #1 go and client #1 sat on
the bed.

Division of Health Service Regulation
STATE FORM

6809

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 8 V 512

If continuation sheet 9 of 17

Division of Health Service Regulation

PRINTED: 05/02/2024
FORM APPROVED

-"[Client #1] was sitting on the bed, jumped up
and started punching [staff #6]."

-"[Staff #6] started hitting [client #1] and at that
point they both were punching and fighting each
other."

-They both fell on the bed.

-Client #1 was lying face up on her back and staff
#6 was face forward on top of client #1.

-"| did see [staff #6] grab [client #1] by her neck,
but | wasn't sure if [staff #6] was choking [client
#4].

-"[Client #1] had got angry and grab [staff #6's]
hair and then [staff #6] grab [client #1's] hair."

-"| was trying to break them up by grabbing [client
#1] and [staff #7] was grabbing [staff #6]."

-"It was loud and chaotic in the room."

-She fell trying to break up client #1 and staff #6
from fighting.

-"[Client #1] and [staff #6] pulled each other's hair
out."

-"Once they both were broken up [staff #6] was
still talking junk to [client #1] and [client #1] was
still trying to fight [staff #6]."

-Staff #6 was the team lead that day and staff #6
was supposed to report all incidents to
management.

-"| wasn't sure if [staff #6] was going to tell the
truth about it."

-"| actually told [Executive Director] that [client #1]
and [staff #6] were fighting each other after
everything had calm down."

-"Management hasn't done any new training since
the incident happened."

Interview on 4/9/24 and 4/23/24 with the RN
revealed:

-She was in the nurse's office and heard a
commotion down the hall around 5:00 -5:30pm.
-"By the time | got down the hallway [client #1]
was in the bathroom with [staff #6]."

Division of Health Service Regulation

STATE FORM

6808 UGOI11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 9 V 512

If continuation sheet 10 of 17

Division of Health Service Regulation

PRINTED: 05/02/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 512] Continued From page 10

-"Me and [staff #6] were coaching [client #1] and
telling her to get up."

-"| reached my hand down toward [client #1] to
help get her up off the floor."

-Client #1 had gotten off the floor and started
walking out of the bathroom.

-"| was walking side by side with [client #1] down
the hallway and [client #1] just darted off."

-Client #1 was trying to get into the community
area.

-Staff stepped in front of client #1 to keep her
from running through the double doors.

-"The staff never made contact with [client #1],
but | can't remember which staff it was."

-Client #1 had ran off into her bedroom.

-She followed client #1 to her bedroom.

-Staff #6, staff #7, and staff #8 were in the
bedroom.

-"We were all talking to [client #1] and trying to
calm [client #1] down."

-"At one point [client #1] was calming down and
then [client #1] started digging at her skin."
-Client #1 had gotten on her bed, laying sideways
with her head towards the floor.

-"[Client #1] was digging in her arms."

-"| walked up toward [client #1's] face saying
‘what's wrong’ and ‘what's going on with you'?"
-"[Client #1] told me that everyone was p*****g
her off."

-Client #1 started calming down again.

-"[Staff #6] turned to walk out the door and [client
#1] jumped off the bed onto [staff #6's] back."
-"[Client #1] wrapped her hand around [staff #6's]
hair and pulled out dreadlocks from [staff #6's]
scalp."

-"| said 'oh wow’ and told [client #1] 'stop'."
-Client #1 pulled staff #6 on the bed while still
holding staff #6's hair.

-"| told [client #1] ‘why you are attacking staff! and
‘let her (staff #6) go’."

Division of Health Service Regulation
STATE FORM

V 512

6808 UGOI11

If continuation sheet 11 of 17

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/24/2024

-"| saw [staff #6] grab [client #1's] hands to get
[client #1's] hands out of [staff #6's] hair."
-"[Staff #7] was helping [staff #6] get [client #1's]
hand out of [staff #6's] hair."

-"When [staff #6] got free [staff #6] walked
straight out the door."

-"| asked [client #1] why did you attack staff?"
-"[Client #1] said that 'B***h choked' me."

-"| immediately assess [client #1] when [client #1]
said that [staff #6] choked her."

-"| looked at [client #1] and did not see any
scratches, redness, and no marks."

-She didn't hear client #1 cough and client #1 was
still yelling and talking.

-"[Staff #7] was in the mix, and | wasn't able to
see everything."

-"| never seen [staff #6] choke [client #1]."

-After the incident was over client #1 was upset
and started crying.

-Staff #6 also started crying after the incident.

-"| checked on [client #1] throughout the
remainder of the evening."

-The incident started at 5:30pm and it was over at
6:00pm.

-"The whole incident only lasted about thirty
minutes."

-"| worked until 12:00am and I'm not sure if [staff
#6] finish the shift or not that night."

-"| sent the incident report and my written
statement to [Director of Operations], [Therapist],
[Executive Director], and [QP]."

-"It was sent from my personal email address
because | don't have a company email address."
-"| sent the email and incident report immediately
because of everything that was going on."

-"| did an incident report immediately due to the
nature of the incident and faxed to upper
management."

-"There hasn't been any new training since the
incident occurred."

Division of Health Service Regulation
STATE FORM

6809

UGOI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 11 V 512

If continuation sheet 12 of 17

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024
FORM APPROVED

(X3) DATE SURVEY

Interview on 4/12/24 with staff #6 revealed:

-"She was called to come down the hall because
[client #1] was having a behavior."

-"When | had gotten down the hall, [client #1] was
in bathroom B."

- | was telling client #1 that she couldn't be in
here.

-"[RN] came into the bathroom and said the same
thing | said to [client #1]."

-"[Client #1] left the bathroom and took off
running toward the double doors where [staff #7]
was standing."

-Staff #7 was talking to client #1 and was trying to
get her to calm down.

-Client #1 had run into client #4's bedroom.
-"[Staff #7] dragged [client #1] from [client #4's]
room to [client #1's] room by a bear hug from the
back."

-Staff #7 was still trying to calm client #1 down.
-Staff #7 was moving stuff off the floor so nobody
would fall and get hurt.

-"| saw [staff #7] push [client #1] onto the bed."

-"| turned around to leave the room because |
thought [client #1] was done."

-"| felt someone jump on my back pulling me
down to the floor by my hair."

-"At first, | thought it was [staff #7] because she
was moving stuff off the floor to prevent everyone
from falling. Once | realized it was [client #1] on
my back pulling my hair."

-"[Client #1] had wrapped her hand around my
hair trying to pull my hair out."

-"| was trying to get [client #1] to stop pulling my
hair and still trying to talk to [client #1] to calm her
down."

-"[Staff #8] helped me get [client #1's] hands out
my hair."

-"[Client #1] said that | choked her, and | did not
choke [client #1]."

Division of Health Service Regulation

STATE FORM

6809

UGOI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 12 V 512

If continuation sheet 13 of 17

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024
FORM APPROVED

(X3) DATE SURVEY

-"| had no reason to choke a child that | care
about so much."

"| had not laid one hand on no child at the facility."
"| did not hit, kick, or pull [client #1's] hair while |
was in the room."

-"| was suspended from the facility and now |
have resigned."

Interview on 4/9/24 with Staff #9 revealed:

-"| was told by [client #1] that a staff had choked
[client #1] in her bedroom."

-"| don't know what staff it was, and | don't
remember the date it happened."

-"| reported the incident to the [Therapist]
immediately."

Interview on 4/9/24 with the Therapist revealed:
-"[Staff #9] called me on my home phone to alert
me about a confrontation between [client #1] and
[staff #6]."

-"| called the acting [[Executive Director] and the
current [Executive Director] directly to let them
know that an incident occurred, and they needed
to get staff off the floor."

-He remembered notifying them about the
incident on March 27, 2024.

-"[Client #1] told me that she was being
non-compliant and two staff escorted [client #1] to
her room."

-While in the room staff #7 had client #1 ina
restraint and then staff #6 came over to assist
staff #7.

-"[Client #1] told me that [staff #6] put her hands
around her neck and that is when [client #1] hit
[staff #6]."

-"[Client #1] told me that once [client #1] hit [staff
#6], that is when they begin fighting each other."
-Management took staff #6 off the floor once the
incident was reported.

-There hasn't been any new training since the

Division of Health Service Regulation

STATE FORM

6809

UGOI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 13 V 512

If continuation sheet 14 of 17

Division of Health Service Regulation

PRINTED: 05/02/2024
FORM APPROVED

incident happened.

Interview on 4/9/24 and 4/23/24 with the
Executive Director revealed:

-"[Staff #9] was talking with [client #1] and [client
#1] told staff #9 that [staff #6] choked her."
-"[Staff #9] reported the incident to [Therapist]."
-"[Therapist] reported the incident to the acting
[Executive Director]."

-"Acting [Executive Director] reported the incident
to me and [Director of Operations]."

-"[Director of Operations] reported the incident to
[Vice President of Operations] who reported it to
DSS."

-"[Client #1] did not tell the staff until a couple of
days later."

-Staff #6 was taken off the schedule immediately
and is currently on suspension until the
investigation is completed.

-"None of the staff told me about the incident the
day it happen."

-"[Staff #6] told me that [client #1] was fighting her
and that was it."

-"[RN], [staff #7], nor [staff #8] did not say
anything to me about [staff #6] fighting [client
#1].

-"| was informed of the incident the next day and
that is when | spoke with all the staff that were in
the room."

-"[Staff #6] finished out her shift at 12:00am and |
stayed until 12am as well."

-The night of the incident was the last day staff #6
worked.

-There hasn't been any new training after the
incident occurred.

Interview on 4/9/24 with the Director of
Operations revealed:

-Client #1 told him that staff #6 choked her.
-"[Client #1] said that [staff #6] pushed her up

Division of Health Service Regulation

STATE FORM

6808 UGOI11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 14 V 512

If continuation sheet 15 of 17

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024
FORM APPROVED

(X3) DATE SURVEY

against the wall with [staff #6's] forearm up
against [client #1's] neck in her bedroom."
-"[Client #1] told me that [staff #6] threw [client #1]
on the bed and choked her."

-Client #1 had gotten upset and jumped on staff
#6.

-"The incident started with [client #1] wanting to
pace the hallway and staff refused to let [client
#1] pace the hallway."

-"[Staff #6] told me that [client #1] had [staff #6's]
hair from the front and was pulling it down."
-"[Staff #6] said that she couldn't see and didn't
know what was going on."

-"[Staff #6] told me that she did not choke [client
#1] or throw [client #1] on the bed."

-The staff were blocking client #1 from coming up
the hallway to keep client #1 from attacking the
other clients.

-The incident was told to staff #9 by client #1
when they both were having a regular
conversation.

-"[Staff #9] reported the incident to [Therapist]."
-"[Therapist] reported the incident to acting
[Executive Director] at the time."

-"Acting [Executive Director] notified [Vice
President of Operations] and me about the
incident."

-"[Staff #6] was taken off the schedule
immediately and is currently on suspension."
-"We haven't done any new training since the
incident occurred."

Review on 4/24/24 of a Plan of Protection written
by the Executive Director dated 4/24/24
revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
The facility will conduct bi-weekly trainings to
ensure staff is knowledgeable of proper

Division of Health Service Regulation

STATE FORM

6809

UGOI11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 04/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 15 V 512

If continuation sheet 16 of 17

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL004-016

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/24/2024

monitoring. Use of appropriate cadence, tone,
and volume and effective de-escalation
techniques. Staff will notify the Executive Director
of any incidents rather they are physical or verbal
to comply with proper use of the chain of
command.

Describe your plans to make sure the above
happens. Senior Team Leader, Team Leaders,
and Leaders will debrief per shift. The Executive
Director will review incident reports and daily
behavior log to ensure compliance. Supervisors
will be conducted with those personnel who do
not comply with facility expectations. Verbal
warning, write ups and supervision will be
conducted. If staff are not in compliance
termination will be recommended."

Client #1 was a 15 year old diagnosed with PTSD
Chronic and ADHD Predominantly Inattentive
Type. An incident occurred on 3/26/24 with client
#1 and staff #6 while client #1 was having a
behavior of yelling and throwing things. During
client #1's behavior episode she hit staff #6 who
in turn started hitting client #1. Staff #6 and client
#1 were punching and fighting each other. At one
point client #1 was face up on the bed with staff
#6 on top of her. Staff #6 and client #1 were also
pulled each other's hair during this fight. Staff #7
and staff #8 had to break up the fight and
separated staff #6 from client #1.

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

Division of Health Service Regulation
STATE FORM

6809

UGOI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 16 V 512

If continuation sheet 17 of 17

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


raw_content:
PRINTED: 01/09/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 B. WING 12/22/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual, complaint and follow up survey was
completed on December 22, 2022. The
complaint was unsubstantiated (Intake
#NC00196021).

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

The facility is licensed for twelve beds and
currently has a census of twelve. The survey
sample consisted of audits of 3 current clients.

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

STATE FORM 6899 P75P11 If continuation sheet 1 of 1


raw_content:
PRINTED: 01/19/2022
FORM APPROVED
Division of Health Service Regulation

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

c
MHL004-016 B. WING _____ 01/12/2022

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

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

DEFICIENCY)

CORNERSTONE TREATMENT FACILITY

V 000} INITIAL COMMENTS Vv 000

An annual, complaints (3) and follow up was
completed on January 12, 2022. Two of the
complaints were substantiated (intake
#NC00184758, #NC00184173). One of the
complaint was unsubstantiated (intake
#NC00184826). Deficiencies were cited.

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

The survey sample consisted of audits of 7
current clients and 3 former clients.

V 367| 27G .0604 Incident Reporting Requirements V 367

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

Division of Health Service Regulation

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

STATE FORM 6899 M1KQ11 If continuation sheet 1 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

(4) description of incident;

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

(6) other individuals or authorities notified
or responding.

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

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

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

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

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

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.

Division of Health Service Regulation

STATE FORM 6899

M1KQ11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 1 V 367

If continuation sheet 2 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

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

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
ailed to ensure a Level II incident report was
completed and submitted to the Local Managed
Entity/Managed Care Organization (LME/MCO)
within 72 hours. The findings are:

Review on 1/10/22 of Client #1's record revealed:
-Admission date of 7/15/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder; Conduct D/O, Unspecified onset type;
ADHD Combined presentation (per history).

Review on 1/10/22 of Client #3's record revealed:

Division of Health Service Regulation

STATE FORM 6899

M1KQ11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 2 V 367

If continuation sheet 3 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

-Admission date of 7/1/21.

-Diagnoses of Unspecified Bipolar Disorder;
Conduct D/O, Childhood onset type; ADHD;
Psychological Abuse (per client hx); Child
Physical Abuse (per client hx); Child Neglect (per
client hx); Child sexual Abuse (per client hx);
PTSD.

Review on 1/10/22 of the Facility's Incident
Reports Notebook revealed:

-Report dated 12/30/21.
-Report completed by the Facility Nurse.

-Incident Report identified as Level Il.

-Clients #1 and #3 were restrained for 5 minutes.
-Any complications resulting from intervention:
Client #1 had generalized pain. Tylenol given 9:18
com with diagnose of pain. Client request.

Review on 1/10/22 of the North Carolina Incident
Response Improvement System (IRIS) revealed
no Level II incident reports for Clients #1 and #3
or the months of December 2021 through
January 2022.

nterview on 1/10/22 with Client #1 revealed:
-She reported that on 12/30/21, she was
restrained. "It was a two staff restraint." One of
he two staff (#11) pushed her elbow up after
placing her arm in the back. She asked the nurse
‘or some ice afterwards, but was given Tylenol.
-Next day, she was still hurting and they then took
her to the hospital.

-Hospital said that she had a broken elbow and
hey were going to report the incident to social
services after she told them what happened.

nterview on 1/10/22 with Client #3 revealed:
-She reported that on 12/30/21, she was also
restrained.

-Staff placed Client #1's hands behind her back.
Division of Health Service Regulation

STATE FORM

6899 M1KQ11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 3 V 367

If continuation sheet 4 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL004-016

NAME OF PROVIDER OR SUPPLIER

CORNERSTONE TREATMENT FACILITY

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

PRINTED: 01/19/2022

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
c
B.WING 01/12/2022

-She did not know if staff may had pushed Client
#1's hands up while restrained.

Interview on 1/10/22 with Staff #11 revealed:

-On 12/30/21, girls had been fighting and clients
had to be restraint.

-Staff #11 also mentioned that one of the clients
had dumped hand sanitizer on the floor and many
of the girls had slipped and fallen to the floor.
Including Client #1.

-Client #1 was pushed down by one of the other
girls as she was falling.

-Client #1 continued to fight afterwards and had
to be restrained again.

-Staff #11 did not know how Client #1 got hurt.
-She denied placing Client #1's hands behind her
back.
-Staff #11 demonstrated restraint. Staff #11
reported that she brought Client #1 's arm to her
side and placed her hip in between while holding
on to her arm.

-Staff #11 reported that she received disciplinary
action from the Director of Operations and all 2nd
shift staff were retrained on physical
interventions.

Interview on 1/10/22 with the Executive Director
(ED) revealed:

-As an ED, she makes sure that incidents related
to restraints are sent to the Vice President of
Operations.

-Whenever there's an allegation of abuse, she
investigated by talking to staff and children to find
out what happened.

-Anything related to abuse, she would send the
information up the chain of command to the Vice
President of Operations.

-Whenever there's an incident related to
restraints, they have 24 hours to submit
paperwork to the Vice President of Operations.
Division of Health Service Regulation

STATE FORM

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

DEFICIENCY)
V 367 | Continued From page 4 V 367

6899 M1KQ11 If continuation sheet 5 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER
129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

-She did not not know how Client #1 got hurt in
the elbow as she was on vacation and did not
return until 1/4/22.

-When she returned to work, she was told that
the girls were getting for bed time and some
started fighting. Staff broke off the fight. -The
behaviors continued. Nurse tried to remove one
of the clients that had been jumped on by others.
She took her to her office and the others
continued to follow her there.

-There was hand sanitizer on the floor as one of
the girls had poured it there to make it slippery.
Some of the girls felled because of the liquid on
the floor, including Client #1.

-Client #1 was placed on a therapeutic hold as
she was being aggressive to staff and other
client. After the incident, Client #1 reported elbow
hurting and nurse gave her pain medication. She
went to sleep and the next day, she continued to
complaint about her elbow hurting.

-Client #1 was then taken to the hospital to have
elbow checked out.

-She did not know why the incident report was not
submitted by the Vice President of Operations to
the IRIS website.

-Since she was out on vacation when the incident
occurred, the Director of Operations conducted
investigation on what occurred.

-She acknowledged that reports were not
submitted to the MCO within 72 hours.

Interview on 1/11/22 with the Director of
Operations revealed:

-IRIS report was to be submitted by the Vice
President of Operations.

-He was unaware as to why it was not in the
system. He was guessing that the Vice President
of Operations may not had clicked on the submit
bottom at the end of the report.

-They had noticed it prior to surveyor visiting the
Division of Health Service Regulation

STATE FORM

6899 M1KQ11

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

DEFICIENCY)
V 367 | Continued From page 5 V 367

If continuation sheet 6 of 9

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL004-016 B. WING

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

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 6 V 367

center. He would follow-up and see what may had
happened.

-He conducted an internal investigation about
what happened on 12/30/21 and how the girl got
injured.

-The girl had been consistent about how she got
hurt during the restraint.

-He believed there was no intent of abuse on
behalf of the staff. Staff may had just done a bad
restraint.

-After the incident, he had a supervisory session
with the staff. Discussed proper restraints. He
asked staff to demonstrate to him that they knew
how to make a restraint. In addition, all second
shift staff received a restraining refresher training
and they had to demonstrate that they knew the
techniques to the instructor. Staff was also placed
on a 90 days probation period.

-He acknowledged that reports were not
submitted to the MCO within 72 hours.

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736
10A NCAC 27G .0303 LOCATION AND

EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be

maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive

odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
findings are:

Division of Health Service Regulation

STATE FORM 6899 M1KQ11

If continuation sheet 7 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL004-016 B. WING

NAME OF PROVIDER OR SUPPLIER

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

Observation on 1/10/22 between 3:41 pm and
4:05 pm of the facility revealed:

-Big Room/Activity Room- Edges of walls were
dirty and had paint peeled off.

-Waall in front of nurse's office- Repaired
patch was not painted over/finished.

-Door to conference room was dirty/stained.
-Room #1- Unfinished repaired patches, they
were not painted. There was a hole in the closet.
Door frame had paint peeled off.

-Room #2- Sheetrock was stripped off from on a
wall and closet.

-Room #3- Sheetrock was stripped off from on a
wall and closet.

-Room #4- Unfinished patch-up work not painted.
There was Graffiti on a wall.

-Bathroom A- Plastic cover on wall next to sink
was broken on the edges. Unfinished patch-up
work was not painted. Wooden door was not
painted/stained.

-Room #5- Sheetrock was stripped from wall by
window and corner of the room.

-Bathroom B- Very loud exhaust fan. Sheetrock
was stripped from one of the walls.

-Room #6- Unfinished patch-up work/ not
painted.

-Room #7- Unfinished patch-up work/not painted.
Sheetrock was stripped off from a wall.

-Room #8- There was Graffiti on closet. Air
Conditioning vent on ceiling was bent forward and
out of placement.

-Room #9- Sheetrock was stripped off from walls.

Interview on 1/10/22 with the Executive Director
revealed:

-She was aware that the facility needed to be
repainted at certain places.

-Indicated that the paint was being peeled off
from the residents at the facility.

Division of Health Service Regulation

STATE FORM

6899 M1KQ11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 7 V 736

If continuation sheet 8 of 9

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL004-016

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

PRINTED: 01/19/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
01/12/2022

-She had put in work orders to repair things
noted.

-She had also put in orders for the facility to be
repainted.

-She confirmed the facility failed to ensure facility
grounds were maintained in a clean, safe and
attractive manner.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

Division of Health Service Regulation
STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 8 V 736

M1KQ11

If continuation sheet 9 of 9


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 07/16/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL004-016 07/07/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

Acomplaint survey was completed on July 7,
2021. The complaint was unsubstantiated (intake
#NC00177198 and NC00178248). No
deficiencies were cited.

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

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

STATE FORM

6899

N11311

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 04/29/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL004-016 B. WING ____ 04/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and complaint survey was completed
on April 26, 2021. The complaint was
unsubstantiated (intake #NC00176177).
Deficiencies were cited.

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

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

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

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

This Rule is not met as evidenced by:

Based on observation and interview, the facility
ailed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
indings are:

Observation on 4/26/21 between 12:33 PM. and
1:00 PM of the facility revealed:
-Bedroom #1- Ceiling light fixture was missing the
ight bulb tubes.
-Bedroom #2- Large section of sheetrock from
he wall was peeled off.

- There was graffiti written on the wall by
he window.
-Bedroom #3- There was graffiti written inside the
irst closet.

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

STATE FORM 6899 61TG511 If continuation sheet 1 of 3

PRINTED: 04/29/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING

MHL004-016 04/26/2021

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

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 1 V 736

- Patched up work on wall inside the first
closet was not painted over.
-Bedroom #4- There was a patch of the sheetrock
on the wall by the light switch that was peeled off.
- There was graffiti written inside the
closet.
-Bathroom A- There was a patch of the sheetrock

on the wall by the light swi
- There was a tile
and to the right that had a

ich that was peeled off.
by the back of the sink
section broken off and

missing.

- There was a patch of the sheetrock on
the wall by the shower that was peeled off.

- Bottom of walls next to the shower were
rotten and starting to disintegrate.

-Bedroom #5- Previous patched up work on the
wall had not been painted over on corner of the
room.

-Bedroom #6- Ceiling light fixture was missing the
ight bulb tubes.

- Section of wall by the window needed to
be repainted as it was also peeled off.

-Bathroom B- Ceiling light fixture was missing the
ight bulb tubes. Using flashlights for lights.
There was a patch of the sheetrock on
he wall by the light switch that was peeled off.

- There was a patch of the sheetrock on
he wall by the toilet that was peeled off.
-Bedroom #7- There was a patch of the sheetrock
on the wall by the light switch that was peeled off.

- There was graffiti written on walls inside
he closet.

- There was a patch of the sheetrock on
he wall to the left that was peeled off.
-Bedroom #8- Inside of closet was dirty and
stained. In need of repainting.
-Bedroom #9- There was a patch of the sheetrock
on the wall by the light switch that was peeled off.
There was a patch of sheetrock on the
wall inside the closet that was peeled off.

Division of Health Service Regulation
STATE FORM

6899 6TG511 If continuation sheet 2 of 3

PRINTED: 04/29/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL004-016 B. WING ____ 04/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 736 | Continued From page 2 V 736

- There was graffiti written inside the
closet.

- Walls were dirty and stained. Needed
repainting.
-Bathroom #C- Handle from faucet was off.

- Ceiling light fixture was missing the
light bulb tubes. Using flashlights for lights.

- Paint from the walls were peeling off.

- There was a patch of the sheetrock on
the wall by the shower that was peeled off.
-Activity Room- Several stains/markings observed
on the ceiling. Walls were dirty/stained.

Interview on 4/26/21 with the Executive Director
revealed:

-She was aware that the facility needed to be
repainted at certain places.

-Indicated that the paint was being peeled off
from the residents at the facility.

-Light bulb tubes were also damaged by a couple
of the residents.

-She had put in work orders to repair the light
fixtures. She informed that plans were to have
new fixtures to be inside the ceiling and not have
the light bulb tubes exposed.

-She had also put in orders for the facility to be
repainted.

-She confirmed the facility failed to ensure facility
grounds were maintained in a clean, safe and
attractive manner.

Division of Health Service Regulation
STATE FORM 6899 61TG511 If continuation sheet 3 of 3

inspection_type: MHLCS Annual and Complaint


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

raw_content:
Division of Health Service Regulation

PRINTED: 03/17/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL004-016 03/09/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

A complaint and follow up survey was completed
on March 9, 2021. The complaint was
unsubstantiated (intake #NC00173884). No
deficiencies were cited.

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

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

STATE FORM

6899

1YG011

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up