state: NC

facility_name: Reuter Cottage

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

raw_content:
Division of Health Service Regulation

PRINTED: 11/12/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 B. WING 10/25/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 October 25, 2019. The complaint
was unsubstantiated (4NC00156310). No
deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 DKVN11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


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

raw_content:
PRINTED: 09/10/2018
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES | (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

R
08/27/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-203 B. WING

NAME OF PROVIDEROR SUPPLIER

REUTER COTTAGE

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION

(X4) ID
eRee (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V000 INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on 8/27/18. Deficiencies were cited.

RECEIVED

By DHSR - Mental Health Lic. & Cort. Section at 11:18 am, Sep 24, 2018

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

V 114 27G .0207 Emergency Plans and Supplies v114
|

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) A written fire plan for each facilityand
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

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

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies

accessible for use.

This Rule is not met as evidenced by: Based a ANS: OD USP NE TROENCY

on record review and interviews, the facility

failed to hold fire and disaster drills on each Eliada’s Residential Treatment Fire and | 9/17/18

shift at least quarterly. The findings are: Disaster Drill Procedures and Drill Log

Review on 8/27/18 of fire and disaster drills from have been revised. (attached for review)

July 2017-June 2018 revealed:
-No documentation of fire drill having been
conducted during:

Revised procedures were reviewed with 9/17/18
Cottage Supervisors on 9/17/18 and

- ‘ Direct Care staff were trained on the new
1st shift from April 2018 through June 2018. procedures and compliance standards

| --2nd shift from October 2017 through December during the Team Supervision Meeting on 9/18/18
9/18/18.

(x6) DATE

cl4911 If continuation sheet 1 of 5

PRINTED: 09/10/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: _ COMPLETED
R
MHL011-203 B. WING 08/27/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
REUTER COTTAGE ASHEVILLE, NC 28806
(4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULDBE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
i 10A NCAC 27G .0207 EMERGENCY
Vv 114 d F, Vv 114
Continued From page 4 PLANS AND SUPPLIES
2017; January 2018 through March 2018 nor April)
2018 through June 2018. Eliada’s Maintenance Supervisor will 10NN8
--3rd shift from January 2018 through March develop an annual schedule for Disaster |
2018 nor April 2018 through June 2018. Drills to ensure that all types are
scheduled with appropriate shift variation.
-No documentation of disaster drill having been The cottage drill log will be compared to
conducted on: this annual schedule by the Residential
--1st shift from January 2018 through March 2018 Administrative Assistant to ensure
nor April 2018 through June 2018. compliance and accuracy.
--2nd shift from January 2018 through March
2018 nor April 2018 through June 2018. As reflected on the Revised Fire and 9/18/18
| ~3rd shift from January 2018 through March Disaster Drill Procedure, the Residential
2018 nor April 2018 through June 2018. Administrative Assistant will monitor drill
- | . completion and documentation monthly:
Interview on 8/27/18 with the Residential Director
revealed: ; I. Drills must be completed by the
-Disaster drills were conducted campus wide by | 15" of each month. Cottage
the maintenance department but each cottage . - dt
was responsible for recording it in their log books. | SUpervisors areireduired|to
-Each cottage had a Program Manager (PM) who scan each cottage’s drill log
was responsible for making sure fire drills were and email to the Residential
completed. Administrative Assistant by the
-The PMs had been providing coverage-filling in 25t each month.
gaps when needed, which had taken most of their
time. ; _. i. The Residential Administrative
-He was responsible for supervising each cottage Assistant will notify the
PM and making sure they followed the corporate . y . |
master schedule. respective Cottage Supervisor, |
-They now have an administrative position who Residential Director and PQI
will be in charge of seeing that fire and disaster team of any incomplete drills on
drills are completed as scheduled. the 26'" each month, or the first
business day following the 25¢.
V 123 27G .0209 (H) Medication Requirements V 123
It. The Residential Administrative
10A NCAC 27G .0209 MEDICATION Assistant will send an email
REQUIREMENTS oo confirmation that all monthly
(h) Medication errors. Drug administration errors drills have been completed by
and significant adverse drug reactions shall be the 1* of the month (for the
reported immediately to a physician or month prior) to the Residential
| Director and PQI
STATE FORM 6800 cl4911 If continuation sheet 2 of 5

Division of Health Service Requiation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHL011-203

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

PRINTED: 09/10/2018

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: oon cee
R
8. WING 08/27/2018

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
scauaieneiedliead ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)
V 123 Continued From page 2 v123 | 10ANCAC 27G .0209
pag MEDICATION REQUIREMENTS
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded Eliada’s Nurse Manager, in consultation | 8/30/18

in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to immediately notify a physician or
pharmacist of medication errors for 2 of 4
sampled clients (Client #3 and Former Client (FC)
#4). The findings are:

Record review on 8/24/18 for Client #3 revealed:
-Admission date of 7/5/18 with diagnoses of
Bipolar Disorder, Oppositional Defiant Disorder
(ODD), Post- Traumatic Stress Disorder (PTSD),
Attention Deficit Hyperactivity Disorder (ADHD)
and Asthma.

Review on 8/24/18 of Incident Reports for Client
#3 from 2/1/18-8/15/18 revealed:

-2 incident reports- one 1 of which was a
medication error.

-Client #3 refused the 8am dose of Loratadine
due to making her sleepy.

-No notification to pharmacist or physician was
made.

Record review on 8/24/18 for FC #4 revealed:
-Admission date of 5/2/18 with diagnoses of
ODD, Disruptive Mood Dysregulation Disorder,
ADHD and Borderline Intellectual Disability.
-Discharge date of 7/12/18.

Review on 8/24/18 of Incident Reports for FC #4
from 5/15/18-7/5/18 revealed:

-15 incident reports- 3 of which were medication

with Eliada’s Medical Director and
Physician’s Assistant revised the
documentation and notification protocol for
medication errors. The new protocol
directs:

e The student's primary care provider
or pharmacy will be notified
IMMEDIATELY in the event of any
medication error. This INCLUDES
medication refusals by the student.

e Ifa psych medication was missed
or an error occurred, Eliada’s
Medicai Director (Psychiatrist) will
be contacted immediately.

e Ifa medication that Eliada’s PA
prescribed was missed or another
error occurred, Eliada’s nursing
department will notify the PA
immediately and seek guidance for
monitoring symptoms.

e Eliada nurses may contact the
pharmacy to provide immediate
notification of student refusals of
medications that were prescribed
by an external physician or to seek
additional recommendations and
advice for monitoring symptoms or
side effects.

e Anincident report is completed for
every medication error. The
administering nurse must document
the medication error notification in
the professional guidance section
of Incident Report, including date/
time and provider notified, as well

STATE FORM

14911

If continuation sheet 3 of 5

PRINTED: 09/10/2018
FORM APPROVED

Division of Health ServiceR

as specific recommendations or

education received.

« The nurse completing the Incident
Report also notifies one lead nurse,
who reviews the incident
documentation and adds their
recommendations and confirmation
of follow-up in the supervisory
debriefing section of the incident
report.

e The Eliada nursing team will

continue to include medication error

reports in the evening

correspondence which provides a

summary of student needs/issues

with the nurse team, Medical

Director, PA, PQ! and Residential

Leadership..

The above protocol was provided to all 8/30/18
in Eliada’s Medical Director and PA. |

Division of Health Service Regulation
STATE FORM 6800 cl4911 If continuation sheet 4 of 5

Division of Health ServiceRegulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: .
A BUILDING:
MHL011-203 8. WING
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES

(X4) ID ID

TAG
DEFICIENCY)

V 123) Continued From page 3 V 123

errors.
--5/15/18-Client left campus for a family visit, did
not take his eye drops and missed his 1pm dose.
"Health Professional Guidance for Medication
Error: Continue with eye drops this evening upon
return." No immediate notification or identification
of who was contacted or when.

--5/28/18-Client "refused his Fluticasone cream
this morning saying he does not need it today."
"Health Professional Guidance for Medication
Error: [Medical Director (MD)] will be notified in
evening report.” No immediate notification was
made.

--6/30/18-"When giving meds this AM, student
noticed an extra med and asked what they were.
I let him know that 3 were for allergies and one
was Guanfacine, he did not allow me to explain
before he refused and started escalating. He
refused mouth check and then refused med
watch and eyesight ..." Client refused medication
through 7/12/18. "Health Professional Guidance
for Medication Error: Per nursing judgment, will
try to begin this medication tomorrow. Will inform
[MD]. [MD] notified evening report for all refused
days." No immediate notification was made.

Interview on 8/27/18 with the Registered Nurse
(RN) revealed:

-There were 13 RNs on staff to cover the entire
campus.

-There were 2 RNs on campus from 6am-10pm.
-Numerous attempts were made to convince
clients to take ordered medications.

-Notified lead RN either by text or phone for any
missed or refused medications.

-Made “nursing judgment" for missed or refused
medications as to what medications required
immediate notification to MD. Otherwise MD
would be notified at evening report.

-The RN had evening report every night between |
Division of Health Service Regulation

STATE FORM e800 14911

PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTIONSHOULD BE | COMPLETE
REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

PRINTED: 09/10/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
08/27/2018

If continuation sheet 5 of 5

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES, (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-203

PRINTED: 09/10/2018
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

R
B.WING - 08/27/2018

REUTER COTTAGE

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY ORLSC IDENTIFYING INFORMATION)

1D PROVIDER'S PLAN OF CORRECTION
PREFIX {EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

V 123) Continued From page 4
|
10pm and 11pm with MD.

Interview on 8/27/18 with the Director of
Performance and Quality Improvement revealed:
-She was unaware of the requirement for
immediate notification to physician or pharmacist
for refused or missed meds as it had never been
cited before.

-"We will figure this out.”

Division of Health Service Regulation
STATE FORM

= cl4911 If continuation sheet 6 of 5

SPI 8107/6 PastAey “7107/01 Poepdn,

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Il.

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IV.

VI.

Vil.

ELXADA

HELPING CHILOREN SUCCEED

Residential Treatment
Fire and Disaster Drill Procedures

Residential Cottage Supervisors complete a review of the Agency Disaster
Plan with each new student admitted to the Cottage within 24 hours.

Residential Programs conduct two Emergency Disaster Drills each month:
e Fire Drill
e Disaster Drill (One disaster drill needs to be done each month; Disaster drills will be initiated

by the Facilities Supervisor. Program staff are required to document the drill and indicate on Drill
Log the type conducted)

o Tornado Drill
Earthquake Drill
Chemical/Hazardous Materials Release

fe)

Evacuation due to a Bomb Threat
Secure Campus Lockdown (Partial and Full)

oo

Monthly Drills will be conducted quarterly on each shift per the schedule
below. Drills are to be conducted under conditions which simulate the
emergency.

Drills may be conducted on the same day provided it is clear they are separate
drills and documented as such, however, it is preferable to do them on
different days when possible.

Drills must be completed by the 15" of each month. Cottage supervisors are
required to scan each cottage’s drill log and email to the Residential
Administrative Assistant by the 25" each month.

The Residential Administrative Assistant will notify the respective Cottage
Supervisor, Residential Director and PQI team of any incomplete drills on the
26" each month, or the first business day following the 25".

The Residential Administrative Assistant will send an email confirmation that
all monthly drills have been completed by the 1* of the month (for the month
prior) to the Residential Director and PQI

Updated 10/2012; 9/2018 kls
S:RESIDENTIAL/Program MGR Residential/Forms & Standards-Residential/Safety and Emergency
Planning/Eliada Res TX Fire and Disaster Drill Procedure 2018

ELYADA

HILOREN SUCCEED

VIIL. Drills are documented on the Drill Log and kept in the cottages RED Safety
Notebook.

a. Paper copies of the drill logs are maintained on site in the RED Safety
Notebook in each cottage for a full calendar year. The Residential
Administrative Assistant will verify that a scanned copy of the drills for
the full year have been received saved, and will then direct the Cottage
Supervisor to shred to the paper copies.

Quarterly Drill Rotation

Responsible 1* Shift 2™4 Shift 3" Shift
Shift

Updated 10/2012; 9/2018 kls
S:RESIDENTIAL/Program MGR Residential/Forms & Standards-Residential/Safety and Emergency
Planning/Eliada Res TX Fire and Disaster Drill Procedure 2018

inspection_type: MHLCS Annual and Follow-up

document_type: Plan of Correction


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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-203

A. BUILDING:

B. WING

2 COMPTON DRIVE

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2018
FORM APPROVED

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY
COMPLETED

R
08/27/2018

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

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

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:
Based on record review and interviews, the
facility failed to hold fire and disaster drills on
each shift at least quarterly. The findings are:

Review on 8/27/18 of fire and disaster drills from
July 2017-June 2018 revealed:

-No documentation of fire drill having been
conducted during:

--1st shift from April 2018 through June 2018.
--2nd shift from October 2017 through December

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

STATE FORM

6899

REUTER COTTAGE ASHEVILLE, NC 28806
(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 follow up survey was completed
on 8/27/18. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 10A NCAC 27G
1700 Residential Treatment Staff Secure for
Children or Adolescents.
V 114) 27G .0207 Emergency Plans and Supplies Vv 114

TITLE

(X6) DATE

cl4911 If continuation sheet 1 of §

PRINTED: 09/10/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-203 B. WING ____ 08/27/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 1 Vv 114

2017; January 2018 through March 2018 nor April
2018 through June 2018.

--3rd shift from January 2018 through March
2018 nor April 2018 through June 2018.

-No documentation of disaster drill having been
conducted on:

--1st shift from January 2018 through March 2018
nor April 2018 through June 2018.

--2nd shift from January 2018 through March
2018 nor April 2018 through June 2018.

--3rd shift from January 2018 through March
2018 nor April 2018 through June 2018.

Interview on 8/27/18 with the Residential Director
revealed:

-Disaster drills were conducted campus wide by
the maintenance department but each cottage
was responsible for recording it in their log books.
-Each cottage had a Program Manager (PM) who
was responsible for making sure fire drills were
completed.

-The PMs had been providing coverage-filling in
gaps when needed, which had taken most of their
time.

-He was responsible for supervising each cottage
PM and making sure they followed the corporate
master schedule.

-They now have an administrative position who
will be in charge of seeing that fire and disaster
drills are completed as scheduled.

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or

Division of Health Service Regulation
STATE FORM 6899 cl4911 If continuation sheet 2 of 5

PRINTED: 09/10/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-203 B. WING ____ 08/27/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123} Continued From page 2 V 123

pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to immediately notify a physician or
pharmacist of medication errors for 2 of 4
sampled clients (Client #3 and Former Client (FC)
#4). The findings are:

Record review on 8/24/18 for Client #3 revealed:
-Admission date of 7/5/18 with diagnoses of
Bipolar Disorder, Oppositional Defiant Disorder
(ODD), Post- Traumatic Stress Disorder (PTSD),
Attention Deficit Hyperactivity Disorder (ADHD)
and Asthma.

Review on 8/24/18 of Incident Reports for Client
#3 from 2/1/18-8/15/18 revealed:

-2 incident reports- one 1 of which was a
medication error.

-Client #3 refused the 8am dose of Loratadine
due to making her sleepy.

-No notification to pharmacist or physician was
made.

Record review on 8/24/18 for FC #4 revealed:
-Admission date of 5/2/18 with diagnoses of
ODD, Disruptive Mood Dysregulation Disorder,
ADHD and Borderline Intellectual Disability.
-Discharge date of 7/12/18.

Review on 8/24/18 of Incident Reports for FC #4
from 5/15/18-7/5/18 revealed:

-15 incident reports- 3 of which were medication
Division of Health Service Regulation

STATE FORM 6899 cl4911 If continuation sheet 3 of 5

PRINTED: 09/10/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-203 B. WING 08/27/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 3 V 123
errors.

--5/15/18-Client left campus for a family visit, did
not take his eye drops and missed his 1pm dose.
"Health Professional Guidance for Medication
Error: Continue with eye drops this evening upon
return." No immediate notification or identification
of who was contacted or when.
--5/28/18-Client "refused his Fluticasone cream
this morning saying he does not need it today."
"Health Professional Guidance for Medication
Error: [Medical Director (MD)] will be notified in
evening report." No immediate notification was
made.
--6/30/18-"When giving meds this AM, student
noticed an extra med and asked what they were.
let him know that 3 were for allergies and one
was Guanfacine, he did not allow me to explain
before he refused and started escalating. He
refused mouth check and then refused med
watch and eyesight ..." Client refused medication
hrough 7/12/18. "Health Professional Guidance
or Medication Error: Per nursing judgment, will
ry to begin this medication tomorrow. Will inform
[MD]. [MD] notified evening report for all refused
days." No immediate notification was made.

nterview on 8/27/18 with the Registered Nurse
(RN) revealed:

-There were 13 RNs on staff to cover the entire
campus.

-There were 2 RNs on campus from 6am-10pm.
-Numerous attempts were made to convince
clients to take ordered medications.

-Notified lead RN either by text or phone for any
missed or refused medications.

-Made "nursing judgment" for missed or refused
medications as to what medications required
immediate notification to MD. Otherwise MD
would be notified at evening report.

-The RN had evening report every night between
Division of Health Service Regulation

STATE FORM 6899 cl4911 If continuation sheet 4 of 5

PRINTED: 09/10/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-203 B. WING ____ 08/27/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123} Continued From page 4 V 123

10pm and 11pm with MD.

Interview on 8/27/18 with the Director of
Performance and Quality Improvement revealed:
-She was unaware of the requirement for
immediate notification to physician or pharmacist
for refused or missed meds as it had never been
cited before.

-"We will figure this out."

Division of Health Service Regulation
STATE FORM 6899 cl4911 If continuation sheet 5 of 5


facility_name: Cynthia's Place

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO011-369

45 EYE VIEW ROAD

CYNTHIA'S PLACE

PRINTED: 07/11/2025

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

) DATE SURVEY
COMPLETED

R
07/10/2025

An Annual and Follow up survey was completed
on July 10, 2025. No deficiencies were cited.

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

The facility is licensed for 4 and currently serving
a census of 3. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

CANDLER, NC 28715
(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

TITLE

(X6) DATE

If continuation sheet 1 of 1

VYXF11


raw_content:
PRINTED: 05/20/2024
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

R
MHL011-369 B. WING _____ 05/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
45 EYE VIEW ROAD
CANDLER, NC 28715

(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)

CYNTHIA'S PLACE

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on 5/17/24. Deficiencies were cited.

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

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

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

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

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

STATE FORM 6899 cwalt1 If continuation sheet 1 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

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 observation, record reviews and
interviews, the facility failed to ensure
medications were administered on the written
order of a physician and that MARs were kept
current affecting 2 of 3 audited clients (#1, #2).

Record review on 5/17/24 for Client #1 revealed:
-Date of admission: 9/5/23
-Age: 17 years old
-Diagnoses: Attention deficit hyperactivity
disorder (ADHD), Autism spectrum disorder,
Generalized anxiety disorder.
-Physician ordered medications included:
-Cetirizine 10 mg (milligram)(allergies) 1
tablet twice daily ordered 2/7/24.
-Cetirizine 10mg 1 tablet once daily ordered
4/16/24.
-Hydroxyzine 10mg (anxiety) 1 tablet 3 times
daily PRN (as needed) for anxiety ordered 2/7/24.

Review on 5/17/24 of Client #1's MARs for March
1 to May 16, 2024 revealed:

-Cetirizine was documented as administered
twice daily from 3/1/24-3/16/24.

-Hydroxyzine was documented as
administered once on 3/13/24, 3/18/24, 3/23/24,
4/7/24.

Division of Health Service Regulation
STATE FORM

6899 cwaltt

(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 V 118

If continuation sheet 2 of 11

PRINTED: 05/20/2024
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: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 05/17/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(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 V 118

-There was no descriptive information on the
back of the MAR to document the time
Hydroxyzine was administered, reason for
administration or effectiveness of the PRN.

Record review on 5/17/24 for Client #2 revealed:
Date of admission: 6/12/23
Age: 14 years old
-Diagnoses: Unspecified mood disorder,
Oppositional defiant disorder, ADHD, Borderline
Intellectual functioning.
-Physician ordered medications included:
-Mirtazapine 45mg (depression) 1 tablet once
daily ordered 2/7/24.

-Mirtazapine 15mg - 1 tablet daily ordered
3/15/24.

Review on 5/17/24 of Client #2's MARs for March
1 to May 16, 2024 revealed:

-Mirtazapine 45mg was documented as
administered 3/1/24-5/16/24.

nterview on 5/17/24 with Client #1 revealed:
-His medications make him really hungry.

-"Takes a good bit of meds (medications) but
don't know what they are."

erview on 5/17/24 with Client #2 revealed:
-Received his medications every day.
-Didn't know what medications he took.

5

nterview on 5/17/24 with the Associate
Professional revealed:

-He was responsible for managing the
medications for the facility.

-Was not aware of Client #1's order for Cetirizine
or once a day administration. "He's always taken
it twice a day."

-"[Client #1]'s mom is very involved and has been
adamant that his medications not change at all."
Division of Health Service Regulation

STATE FORM 6899 cwalt1 If continuation sheet 3 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 3 V 118

-"| always sit in on the virtual visits with the
psychiatrist."

-All Client #1 meds were electronically sent to
pharmacy on 4/16/24. "I don't understand why
the additional script was sent."

-"| sort of remember that being a requirement (to
record PRN data on the back of the MAR). |
guess it just fell off."

-"Meds are delivered to the lock box. | separate
meds along with overflow meds. Someone
walked in and asked me a question. | may have
been writing that change (for Client #2) and got
distracted."

-"| remember talking about a med change and
talking with [Client #2]."

-The March MAR didn't get changed and just
continued to copy that one.

-"I'm typically on my game; just an oversight."
-Will send email to the group when there are med
changes.

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

Division of Health Service Regulation

STATE FORM 6899

cwaltt

If continuation sheet 4 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

(1) 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

Division of Health Service Regulation

STATE FORM 6899

cwaltt

(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

If continuation sheet 5 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(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
failed to ensure a Level II incident report was
completed within 72 hours and submitted to the
Local Management Entity/Managed Care
Organization. The findings are:

Record review on 5/17/24 of internal incident

Division of Health Service Regulation

STATE FORM 6899

cwaltt

(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 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

reports revealed:

-On 4/20/24 at 11:30am, Client #1 exhibited "self
injurious behavior", "property damage" and "was
out of area and refusal to follow prompts by staff"
due to "anxiety from job interview and loss of
preferred coping skills." Also checked on the
incident report was "escort" and "physical
restraint."

Review on 5/17/24 of facility group email from
Staff #2 dated 4/20/24 regarding Client #1
revealed:

-"This morning started out a little rough. [Client
#1] was chomping at the bit about his job
interview ...| informed him that he needed to calm
himself about it as he was already getting himself
worked up ...As soon as chores were done we
took [Client #1] to [local grocery]. The manage
informed us she couldn't do an interview as she
already short staffed by 7 people ....[Staff #3] said
{Client #1]'s station was left a mess ...| let
[Client#1] know that he wouldn't have any media
today ...I told him | needed him to calm down and
take responsibility for not having his station left in
an acceptable condition ...He responded with
different excuses about his grades not being his
fault while try to get him calmed down he would
shutdown and completely overwhelm himself with
stress. | informed him that if he couldn't maintain
composure to talk | was going to send him to his
room till he calmed down ...instead of going in a
controlled manner he started slamming stuff
around and stomping up the stairs ...1 followed
him upstairs to find him locked in the back
bathroom in told him he needed time out where |
could monitor him for safety purposes he came
out but quickly became unresponsive and
aggressive punching a hole in his bedroom wall
and trying to punch himself me and [staff #3] tried
restraining him | his room while offering to try and
Division of Health Service Regulation

STATE FORM

6899 cwaltt

(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 6 V 367

If continuation sheet 7 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 7 V 367

get a PRN (as needed medication) he was
completely unresponsive only trying to punch and
kick and head but the wall. After only a few
minutes we escorted him to the living room where
we could restrain him sitting on the clinch it took a
ew minutes and he was able to calm down he
ook full responsibility for his behavior apologized
and accepted his consequences ..."

Review on 5/16/24 of IRIS (incident response
improvement system) reports for the facility
revealed:

-No report for Client #1 was found under the
acility or the Licensee's name.

nterview on 5/17/24 with the Associate
Professional revealed:

-Did not know all the details of the incident but
should have collected more information.

-He or the Qualified Professional should have
completed the IRIS report.

V 521} 27E .0104(e9) Client Rights - Sec. Rest. & ITO Vv 521
10A NCAC 27E .0104 SECLUSION,
PHYSICAL RESTRAINT AND ISOLATION
TIME-OUT AND PROTECTIVE DEVICES USED
FOR BEHAVIORAL CONTROL

(e) Within a facility where restrictive interventions
may be used, the policy and procedures shall be
in accordance with the following provisions:

(9) Whenever a restrictive intervention is utilized,
documentation shall be made in the client record
to include, at a minimum:

(A) notation of the client's physical and
psychological well-being;

(B) notation of the frequency, intensity and
duration of the behavior which led to the
intervention, and any precipitating circumstance

Division of Health Service Regulation

STATE FORM 6899

cwaltt

If continuation sheet 8 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

contributing to the onset of the behavior;

(C) the rationale for the use of the intervention,
the positive or less restrictive interventions
considered and used and the inadequacy of less
restrictive intervention techniques that were used;
(D) a description of the intervention and the date,
time and duration of its use;

(E) a description of accompanying positive
methods of intervention;

(F) a description of the debriefing and planning
with the client and the legally responsible person,
if applicable, for the emergency use of seclusion,
physical restraint or isolation time-out to eliminate
or reduce the probability of the future use of
restrictive interventions;

(G) a description of the debriefing and planning
with the client and the legally responsible person,
if applicable, for the planned use of seclusion,
physical restraint or isolation time-out, if
determined to be clinically necessary; and

(H) signature and title of the facility employee
who initiated, and of the employee who further
authorized, the use of the intervention.

This Rule is not met as evidenced by:

Based on record reviews and interview, the
facility failed to ensure the necessary
documentation was in the client record when a
restrictive intervention was utilized affecting 1 of 3
audited clients (#1). The findings are:

Refer to tag V367 for incident details

Review on 5/17/24 of facility records revealed:
-There was no documentation of the description
of the intervention and the date, time and duration
of its use.

-No notation of Client #1's physical and

Division of Health Service Regulation

STATE FORM

6899 cwaltt

(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 521] Continued From page 8 Vv 521

If continuation sheet 9 of 11

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-369 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 521] Continued From page 9 V 521

psychological well-being.

-No documentation of the signature and title of
the facility employee who initiated the use of the
intervention.

Interview on 5/16/24 with Client #1 revealed:
-"Had a minor restraint in my room ...lot of things
went wrong that days, so much anxiety sort of
blacked out, punched a hole in the wall."

Interview on 5/17/24 with the Associate
Professional revealed:

-They had not used a restrictive intervention in
some time at the facility.

-Was aware of the processes, it had just been a
while since he needed to remember them.

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
was not maintained in a safe, clean, attractive
and orderly manner. The findings are:

Observation on 5/16/24 at approximately 4pm
revealed:

-Pedestal sink in back bathroom not attached to
the wall.

-Medicine cabinet in back bathroom rusted
around lower edges inside cabinet.

-Light brownish colored stains in toilets in back
bathroom as well as hall bathroom.

Division of Health Service Regulation

STATE FORM 6899 cwaltt

If continuation sheet 10 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-369

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

45 EYE VIEW ROAD
CANDLER, NC 28715

CYNTHIA'S PLACE

PRINTED: 05/20/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/17/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

-Small 4"x 6" oval hole between beds in bedroom
on the right.

-Light brownish colored strains around bathtub in
hall bathroom.

-Light fixture in hall bathroom middle light bulb
socket was hanging loose.

-Small 2"x 12" tile threshold at hall bathroom
cracked and missing pieces.

Interview on 5/17/24 with the Associate
Professional revealed:

-Water at the facility had a lot of iron in it leaving
rust stains. Have an elaborate water filtration
system but the iron stains reappeared. "Just
takes a little more elbow grease to remove."
-The water was tested annually with no concerns.

This deficiency constitutes a recite deficiency and
must be corrected within 30 days.

Division of Health Service Regulation
STATE FORM

6899

cwaltt

(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 10 V 736

If continuation sheet 11 of 11


raw_content:
PRINTED: 03/30/2022

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: COMPLETED
A. BUILDING:
R
MHL011-369 03/11/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
45 EYE VIEW ROAD
CYNTHIA'S PLACE
CANDLER, NC 28715
(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 Follow up survey was completed

on March 11, 2022. Deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G .1700 Residential

Treatment Staff Secure for Children or

Adolescents.

The facility is licensed for 4 and currently serving

a census of 4. The survey sample consisted of

audits of 3 current clients.

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 record reviews, observations, and
interviews, the facility was not maintained in a
safe, clean, attractive, and orderly manner. The
findings are:

Observation on 3-10-22 at 2:00 pm of the interior
of the home revealed:

-The door to bedroom #1 had two holes in the
outside hallway side of the door.

-The two holes were each approximately 6-8
inches in diameter.

-The door to bedroom #2 had a crack/break in the
lower third of the door.

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

STATE FORM If continuation sheet 1 of 2

TITLE

809 1YQo11

(X6) DATE

PRINTED: 03/30/2022

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
R
MHL011-369 03/11/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 45 EYE VIEW ROAD
CYNTHIA'S PLACE
CANDLER, NC 28715
(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

Review on 3-11-22 of purchase order receipt
revealed:

-Two interior doors were purchased from Lowe's
on 3-11-22.

Interview on 3-10-22 and 3-11-22 with the House
Manager/Associate Professional revealed:

-Was not exactly sure when the holes were put in
the two bedroom doors.

-Two doors had been ordered to replace the
damaged doors, but they were on backorder and
there was a 6-8 week delay for shipping.

-Back in December after construction came out,
there was no follow up to the status of the doors
being ordered.

-Two doors were purchased (on 3-11-22) and
maintenance was made aware in order to come
install them.

Division of Health Service Regulation
STATE FORM

6809

1YQo11

If continuation sheet 2 of 2


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/06/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-369 B. WING 09/03/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
" 45 EYE VIEW ROAD
CYNTHIA'S PLACE CANDLER, NC 28715
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on 9/3/19. The
complaint was unsubstantiated (intake
#NC153888). No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.
Division of Health Service Regulation
TITLE (X6) DATE

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

STATE FORM

6899

V1LI11

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


raw_content:
PRINTED: 06/27/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(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 follow up survey was completed
on 6/17/19. Deficiencies were cited.

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

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure medication errors were reported
immediately to a physician or pharmacist
affecting 2 of 4 clients (Client #1 and Client #3).
The findings are:

Record review on 6/13/19 for Client #1 revealed:
-Admission date on 1/31/19 with diagnoses of
Adjustment Disorder, Oppositional Defiant
Disorder (ODD), Attention Deficit Hyperactivity
Disorder (ADHD) and Neurodevelopmental
Disorder.

-Age-15 years

-Ordered medications included Vyvanse for

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

STATE FORM 6899 JBWS11 If continuation sheet 1 of 6

PRINTED: 06/27/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 1 V 123

ADHD, Clonidine for ADHD, Latuda for
depression, Trazadone for depression,
Clotrimazole for rash, Griseofulvin Ultra for fungal
infection and Gavilax Powder for constipation.

Record review on 6/13/19 for Client #3 revealed:
-Admission date on 4/10/19 with diagnoses of
Mild Intellectual Disability, ADHD and
Post-Traumatic Stress Disorder (PTSD).
-Age-15 years

-Ordered medications included Vyvanse for
ADHD, Aripiprazole for depression, Divalproex for
behaviors, Lithium Carbonate for bipolar,
Melatonin for sleep, Clonidine for ADHD,
Neutrogena Cream for rash, Clindamycin for
acne and Hydroxyzine for anxiety.

Review on 6/13/19 of incident reports from
January - May 2019 revealed:

-6 reports of missed medications

-On 1/21/19 Client #1 missed a medication. No
specific medication was listed and no
documentation of physician or pharmacist
contact.

-On 2/3/19 Client #3 missed a medication. No
specific medication was listed and no
documentation of physician or pharmacist
contact.

Interview on 6/14/19 with the Associate
Professional (AP) revealed:

-He was responsible for supervising staff in this
home.

He had trained staff to document incident reports
for any missed or refused medications as soon as
is realized or discovered as well as contacting a
pharmacist or physician.

-He was not aware staff had not completed the
entire report but thought staff had probably
contacted the pharmacist.

Division of Health Service Regulation

STATE FORM 6899 JBWS11 If continuation sheet 2 of 6

PRINTED: 06/27/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

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

DEFICIENCY)
V 123} Continued From page 2 V 123

-He would be retraining staff to make that
pharmacy contact and document completely
when any medication is missed.

V 294) 27G .1702 Residential Tx. Child/Adol -Req. forQ | V 294
P

10A NCAC 27G .1702 REQUIREMENTS OF
QUALIFIED PROFESSIONALS

(a) Each facility shall utilize at least one direct
care staff who meets the requirements of a
qualified professional as set forth in 10A NCAC
27G .0104(18). In addition, this qualified
professional shall have two years of direct client
care experience.
(b) For each facility of five or less beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
10 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and presen’
he facility.
(c) For each facility of six or more beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
32 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and presen’
he facility.

(d) The governing body responsible for each
acility shall develop and implement written
policies that specify the clinical and administrative
responsibilities of its qualified professional(s). At
a minimum these policies shall include:

(1) supervision of its associate
professional(s) as set forth in Rule .1703 of this
Section;

In

In

Division of Health Service Regulation
STATE FORM 6899 JBWS11 If continuation sheet 3 of 6

PRINTED: 06/27/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CANDLER, NC 28715
(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)

CYNTHIA'S PLACE

V 294] Continued From page 3 V 294

(2) oversight of emergencies;

(3) provision of direct psychoeducational
services to children or adolescents;

(4) participation in treatment planning
meetings;

(5) coordination of each child or
adolescent's treatment plan; and

(6) provision of basic case management
functions.

This Rule is not met as evidenced by:

Based on interviews and record reviews the
acility failed to ensure the qualified professional
(QP) performed a minimum of 10 hours per week
of clinical and administrative services in the
acility, 70% of the time when clients were awake
and present. The findings are:

Record review on 6/13/19 for QP revealed:
-Date of hire-5/8/14

-Job descriptions for both QP and Associate
Professional (AP).

Review on 6/14/19 of QP log revealed:
-Documentation of 10 or more hours for
2/25/19-3/3/19.

-Documentation of 10 or more hours for
3/4/19-3/10/19.

-Documentation of 10 or more hours for
3/11/19-3/17/19.

No other documentation of QP time in the facility
was available.

Interview on 6/14/19 with the AP revealed:
Division of Health Service Regulation
STATE FORM 6899 JBWS11 If continuation sheet 4 of 6

PRINTED: 06/27/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL011-369 B. WING _____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE CANDLER, NC 28715

(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 294] Continued From page 4 V 294

-The QP had been involved in a horrific accident
playing basketball that involved a severe head
injury just 2 days prior. He felt like the QP had
the documentation of facility time for March thru
May 2019 with him but was reluctant to bother
him with work concerns.

-He and the QP worked well together between
this facility and a sister facility where they
switched QP/AP roles. They both were in the
facility more than the required time.

Interview on 6/13/19 with Clients #1 and #2
revealed:

-The QP was in the facility at least twice weekly.
The QP and the AP conducted groups and
provided 1:1 support when needed.

V 297| 27G .1705 Residential Tx. Child/Adol - Req. for L | V 297
P

10A NCAC 27G .1705 REQUIREMENTS OF
LICENSED PROFESSIONALS

(a) Face to face clinical consultation shall be
provided in each facility at least four hours a
week by a licensed professional. For purposes of
this Rule, licensed professional means an
individual who holds a license or provisional
license issued by the governing board regulating
a human service profession in the State of North
Carolina. For substance-related disorders this
shall include a licensed Clinical Addiction
Specialist or a certified Clinical Supervisor.

(b) The consultation specified in Paragraph (a) of
this Rule shall include:

(1) clinical supervision of the qualified
professional specified in Rule .1702 of this
Section;

(2) individual, group or family therapy
services; or

Division of Health Service Regulation
STATE FORM 6899 JBWS11 If continuation sheet 5 of 6

PRINTED: 06/27/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-369 B. WING ____ 06/17/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
45 EYE VIEW ROAD
CYNTHIA'S PLACE
CANDLER, NC 28715
(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 297| Continued From page 5 V 297
(3) involvement in child or adolescent
specific treatment plans or overall program
issues.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure services from a licensed Clinical
Addiction specialist or a certified Clinical
Supervisor for clients with substance-related
disorders affecting 1 of 4 current clients (Client
#2). The findings are:

Record review on 6/13/19 for Client #2 revealed:
-Admission date on 12/3/18 with diagnoses of
Oppositional Defiant Disorder and Cannabis Use
Disorder.

-Age-14 years

Interview on 6/14/19 with Associate Professional
(AP) revealed:

-The LP was a Licensed Clinical Social Worker
(LCSW).

-He was not aware they needed to refer clients
with substance use issues to substance abuse
professionals.

Division of Health Service Regulation
STATE FORM 6899 JBWS11 If continuation sheet 6 of 6


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHLO011-369

NAME OF PROVIDER OR SUPPLIER

PRINTED: 06/05/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

45 EYE VIEW ROAD

CYNTHIA'S PLACE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/05/2018

CANDLER, NC 28715
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual survey was completed on 6/5/18. One
deficiency was cited.
This facility is licensed for the following service
categories:
10A NCAC 27G .1700 Residential Treatment for
Children and Adolescents -Level III
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 observations and interviews, the Client
bedroom flooring in the facility was not
maintained in a clean, attractive manner. The
findings are:

Observations on 6/4/18 at 1:30 PM revealed the
following items to be in need of cleaning or
replacement:

The facility's two client bedrooms were carpeted;
the carpet had several dark stains throughout
both rooms. These stains appeared in door
entranceways and beside beds where use was
greatest and spills appearently occurred over
time.

The carpet in in both client bedrooms also
needed to have a general all purpose cleaning
due to darkening of the carpeting from foot traffic.

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

STATE FORM

TITLE

6808 PGJ911

(X6) DATE

If continuation sheet 1 of 2

PRINTED: 06/05/2018

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
MHLO011-369 06/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 45 EYE VIEW ROAD
CYNTHIA'S PLACE
CANDLER, NC 28715
(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

Interview on 6/5/18 with the QP revealed:

The carpet had been stained by client spills over
time. Staff had attempted to spot clean areas
where spills occurred.

The QP was very cooperative and planned to
attempt to steam clean the carpeting
immediately.

Division of Health Service Regulation
STATE FORM

6809

PGJ911

If continuation sheet 2 of 2

inspection_type: MHLCS Annual


facility_name: Mary Benson House

raw_content:
PRINTED: 02/06/2026

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
R
MHL011-384 02/05/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 follow up survey was completed

on February 5, 2026. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .4100 Residential
Recovery Programs for Individuals with
Substance Abuse Disorders and Their Children.

This facility is licensed for 12 and has a current
census of 5. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

TITLE (X6) DATE

If continuation sheet 1 of 1


raw_content:
PRINTED: 12/16/2024
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

R
MHL011-384 B. WANG _____ 12/06/2024 4

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

450 MONFORD AVENUE
MARY BENSON HOUSE ASHEVILLE, NC 28801

(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)

V000 INITIAL COMMENTS | VooO

An annual and follow up survey was completed
on 12/6/24. Deficiencies were cited. |

| This facility is licensed for the following service
| category: 10A NCAC 27G .4100 Residential | |
| Recovery Programs for Individuals with |

| Substance Abuse Disorders and Their Children. |

| This facility is licensed for 12 and currently has a
census of 5. The survey sample consisted of
| audits of 3 current clients.

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

10A NCAC 27G .0209 MEDICATION | |
REQUIREMENTS | |
(c) Medication administration |
(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by lawto 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. REC E IVED |
(4) A Medication Administration Record (MAR) of DEC 3 0 2024
all drugs administered to each client must be kept | b
current. Medications administered shall be HSR nn
| recorded immediately after administration. The MH Licensure Seat
MAR is to include the following:
(A) client's name;
(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;
(D) date and time the drug is administered; and
(E) name or initials of person administering the
Division of Health Service Regulation
(X68) DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
zs , j f/f af i
——_ tucta Cnyebe Begara] pyrite 12/24/24

STATE FORM 190911 If continuation sheet 1 of 7

|
|

Division of Health Service Regulation

PRINTED: 12/16/2024
FORM APPROVED

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

MHL011-384

(X2) MULTIPLE CONSTRUCTION

A. BUILDING: COMPLETED
R
BANS — 12/06/2024

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

MARY BENSON HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE

450 MONFORD AVENUE
ASHEVILLE, NC 28801

PROVIDER'S PLAN OF CORRECTION

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 ensure medications were
administered on the written order of a physician
affecting 1 of 3 audited clients (#2) and failed to
ensure staff who administered client medications
were trained by a legally qualified and privileged
person who could prepare and administer
medications affecting 3 of 3 staff (Staff #1, Staff
#2 and Program Manager/Qualified Professional
(PM/QP)). The findings are:

Review on 12/3/24 of Client #2's record revealed:
-Date of Admission: 2/20/24.

-Diagnoses: Opioid Use Disorder, Sedative Use
Disorder, Amphetamine Use Disorder, Bipolar
Disorder, Post Traumatic Stress Disorder.
-Physician ordered medications dated 2/22/24
included:

-Ibuprofen 200mg (milligram) (pain) 2 tablets
every 6 hours PRN (as needed) not to exceed 6
tab (tablets) in 24 hour period.

-Acetaminophen 325mg (pain) take 2 tablets
every 6 hours PRN not to exceed 10 tabs in 24
hours.

Review on 12/5/24 of Client #2's MARs for period
9/1/24-12/3/24 revealed:

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES | 1D (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) } Tao | CROSS-REFERENCED TO THE APPROPRIATE DATE
| | DEFICIENCY)
. |
V 118 Continued From page 1 Vv 118

|
A Nurse at RHA held an in service training was 12/23/2024
held with all current staff members at Mary

Benson House (MBH) on 12/17/2024 and

12/19/2024 to provide training regarding the

competencies of Medication Management. The

residents of MBH self-administer their own

medications and the staff members oversee the |

medication monitoring.

Training included that the MAR would indicate if

a resident was not at the facility on a particular

day (on a day pass, overnight, in the hospital,

etc); this would be identified by documentation

lon the MAR. Additionally, training included

information regarding outreaching the pharmacy/

physician for accurate medication orders.

Monitoring of this process will be completed

through Service Record Review Process.

(Attachment A)

Moving forward, all new staff members will have 12/23/2024
a two part training to ensure this training is

completed. The “Your Role in the Medication

Process” will be followed by an In Service with |

an RHA Nurse called “Rights of Medication”
which will be tracked in RHA’s Learning
Management System. The in service for the
December 2024 and future trainings will be
uploaded to the Learning Management System
for tracking.

(Attachment B)

Division of Health Service Regulation
STATE FORM

6899

790911 'f continuation sheet 2 of 7

PRINTED: 12/16/2024

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: COMPLETED
A. BUILDING: __ =
R
MHL011-384 B. WING _ —= 12/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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)

V118 Continued From page 2 Vv 118

-lbuprofen was documented as 3 tablets were

administered at one administration time on
| 9/4/25, 9/5/24 (two times), 9/6/24 (three times),
9/8/24 (two times), 9/10/24 (three times), 9/11/24
(two times), 10/30/24 (two times), 11/29/24 (two
times), 11/30/24 (three times).
Additionally, ibuprofen was documented as
administered a total of 12 tablets on 9/7/24, 14
total tablets on 9/8/24, 10 total tabs 9/9/24, 11 |
total tablets 9/10/24, 7 total tablets 9/11/24, 8 total |
tablets 9/12/24, 9 total tablets 10/31/24, 7 total
tablets 11/1/24 and 11 total tablets on 11/30/24.

-Acetaminophen was documented as

administered 3 tablets at one administration time
on 9/6/24, 9/10/24 (three times), 9/11/24,
11/30/24. |

Review on 12/6/24 of Staff #1's record revealed:
-Date of hire: 3/4/24

-Training transcript included "Your role in the
medication process" online training on 3/11/24.

Review on 12/6/24 of Staff #2's record revealed:
-Date of hire: 9/3/24 |
-Training transcript included "Your role in the |
medication process" online training on 9/16/24 |

Review on 12/6/24 of PM/QP's record revealed: | |
-Date of hire: 1/30/17 | |

| -Training transcript included "Your role in the
medication process" online training on 12/11/23.

Interview on 12/3/24 with Client #2 revealed:

-Had oral surgery early September ..."all upper

teeth were removed and 2 on the bottom ..." |

-"Had papers (instructions from the dentist) telling

| me how many Tylenol (acetaminophen) and
ibuprofen | could take. | don't think | took more

| than | was supposed to...nothing else | could

| have for pain except ibuprofen and tylenol ...went |

Division of Health Service Regulation

STATE FORM 6899 T90911 If continuation sheet 3 of 7

Division of Health Service Regulation

PRINTED: 12/16/2024
FORM APPROVED

|
|
back and forth between the two ..." |
-"lwas an IV (intravenous) user and they couldn't

| give me anything for pain ..."

Interview on 12/6/24 with the contracted
pharmacist revealed

-It was typical for both ibuprofen and
acetaminophen to be taken together. |
-The daily maximum of ibuprofen was 2400mg |
and for acetaminophen was 4000mg |

-"Short term doses exceeding these limits was
not concerning although not recommended |
Long term dosing at this level would not be |
sustainable." Toxicity/overdose level for
acetaminophen was 12,000mg and 30 grams
form ibuprofen. Possible effects could be
cardiovascular events, Gl (gastrointestinal)
bleeds, kidney/liver damage.

Interview on 12/6/24 with Staff #1 revealed: |
-She was responsible for "all things medical" at
the facility.

~Client #1 had dental surgery on 9/4/24 to remove
all upper teeth. "They (dentist) left chunks of
tooth (in her gums)."

-While staff only observed administration, "they
should not have allowed [Client #2] to self
administer more than ordered."

-There were no additional orders from the |
dentist/oral surgeon. |
-"| spoke to [licensee's Medical Director] and to
[Client #2] regarding taking too many ibuprofen |

Interview on 12/6/24 with the PM/QP revealed:
-Started as new PM on 8/5/24. Worked with
agency in other positions though not at the

facility |
-"| did not have med (medication) administration
_ training with a nurse.” | |

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLO011-384 B. WING ——— 12/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE o
ASHEVILLE, NC 28801
(4) 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
TAS REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V118 Continued From page 3 Vv 118

Division of Health Service Regulation

STATE FORM 899

T90911

If continuation sheet 4 of 7

Division o

f Health Service Regulation

PRINTED: 12/16/2024
FORM APPROVED

[

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO011-384

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY “|
A. BUILDING: _ COMPLETED

R
B. WING — 12/06/2024

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all medication
administration errors were reported immediately
to a pharmacist or physician affecting 2 of 3
audited clients (#1, #2). The findings are:

Review on 12/3/24 of Client #1's record revealed:
-Date of Admission: 8/29/24
-Diagnoses: Major Depressive Disorder,

| Substance Use Disorder.
| -Physician ordered medications dated 9/12/24

included:
-Westab Plus 27mg (milligram) (prenatal
supplement) 1 tablet daily.

Review on 12/5/24 of Client #1's medication

MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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)
j
V118 Continued From page 4 | V118 |
| This deficiency constitutes a recited deficiency |
and must be corrected within 30 days. | |
| |
|
| Fg r |
V 123 27G .0209 (H) Medication Requirements | V 123

| Medication error reports will be completed and | 12/23/2024
submitted by Mary Benson House within the |
‘state reporting timelines of a medication error
incident. MBH staff will receive in-service training
regarding medication error reporting to include a |
review of the Quick Mar system which includes
when a medication error has occurred, what
events are considered a medication error, the
procedure to notify the pharmacy and/or
physician, and how to complete the medication
error form. Medication errors will be tracked |
through RHA’'s Incident Management System.
Monitoring of this process will be completed |
through the Service Record Review Process and
the local QAPI.

{Attachment C) |

Division of Health Service Regulation

STATE FORM

6899 If continuation sheet 5 of 7

T90911

Division of Health Service Regulation

PRINTED: 12/16/2024

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

MHLO01 1-384

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A BUILDING. COMPLETED
R
& MING 12/06/2024

NAME OF PROVIDER OR SUPPLIER,

MARY BENSON HOUSE 480. MONE

STREET ADDRESS, CITY, STATE, ZIP CODE

ORD AVENUE

ASHEVILLE, NC 28801

SUMMARY STATEMENT OF DEFICIENCIES |

(X4) ID
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL
Tac | REGULATORY OR LSC IDENTIFYING INFORMATION)

| PROVIDER'S PLAN OF CORRECTION

Vv 123 Continued From page 5

administration record (MAR) for period
9/1/24-12/3/24 revealed:

-Westab was documented as refused on
10/25/24, 10/26/24, 11/15/24, 11/16/24, 11/18/24,
11/21-12/3/24. (18 doses)

Review on 12/3/24 of Client #2's record revealed: |
-Date of Admission: 2/20/24. |
-Diagnoses: Opioid Use Disorder, Sedative Use |
Disorder, Amphetamine Use Disorder, Bipolar |
|
|

Disorder, Post Traumatic Stress Disorder
-Physician ordered medications dated 2/22/24
included:

-Naltrexone 50mg (reduce cravings) 1 tablet
daily ordered 5/22/24.

-Prenatal Tablet 27mg (prenatal supplement) |
1 tablet daily for high risk pregnancy ordered |
3/27/24.

-Quetiapine 100mg (anxiety) 1 tab daily at
bedtime ordered 10/29/24

Review on 12/5/24 of Client #2's MAR for period
9/1/24-12/3/24 revealed:

-Naltrexone was documented as not administered |
on 9/22/24, 9/23/24,11/16/24. (3 doses) |

-Prenatal tab was documented as refused

9/4/24, 9/7/24. (2 doses)

| -Quetiapine was documented as refused on
| 11/25/24. (1 dose)

Interview on 12/6/24 with Staff #1 revealed:
-She was responsible for "all things medical" at |
the facility. |
-Had trained staff regarding completing med
(medication) error reports and contacting the
pharmacy.

-"The previous Program Manager did not require
| med error reports for exceptions like 'physically
unable to take’ or med not in facility’. Now send
| med error form to [Licensee's medical Director]."

ID (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)
V 123

Division of Health Service Regulation

STATE FORM 6

899 If continuation sheet 6 of 7

790911

Division of Health Service Regulation

PRINTED: 12/16/2024
FORM APPROVED

Vv 123 | Continued From page 6

Will be in-servicing all staff on completing med
error reports |

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BONDING COMPLETED
R
MHL011-384 BIN ones 12/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)
V 123

Division of Health Service Regulation
STATE FORM

6898

790911 \f continuation sheet 7 of 7

_ Attachment A
#RHA =e

In-service Traming

Date; Place Held:

Title of Training:

HEALTH SERVICES,

RN reviewed the rights of medication training on MAR documentation to include
documenting if a person is not present at the facility on a day/weekend. RN trained on
competencies of staff to oversee monitoring of residents’ medications.

Attendance

Printed Name Pe Signatye Work bocation |

Second Instructors Name ~ ~~ Title/Credentials Instructor's Signature

Last Modified: 11/07/2012 Form#: 11005

AX RHA

botnet In-service Training
VU\I (24 Mary Benson ADVE — [End Time: 9,00

Title of Training: Metication AaminiSr>tyton

Purpose/Outline of Training:

RN reviewed the rights of medication; training on MAR documentation to include
documenting if a person is not present at the facility on a day/weekend. RN trained on
competencies of staff to oversee monitoring of residents’ medications.

ie : Attendance

: ~ Printed Name g
7S

—————————— sy,

Date:

Second Instructor's Name Title/Credentials ~ Instructor's Signature

Last Modified: 11/07/2012 Form#: 11005

12/23/24, 7:45 AM View Blended Course - Workday

= MENU Ww Q Rights of Medication (C3) Attachment B
7 Rights of Medication =] bok

ao

2 Description A licensed nurse will train staff on the rights of medication.jpg

medication before they can “supervise” the self ad-
ministration of medication of persons served. This

Q in-service should occur following the completion of
the digital course BH and Your Role in the
Medication Process.

Uploaded by Erika Harrelson (017707)

ols Course Number (empty)
Content Provider Internal
Legacy Course No
Date Added 12/19/2024
Ww Topics Behavioral Health
New Employee Orientation
~ Language (empty)
Skill Level (empty)
Contacts (empty)

Requires Enrollment Yes

Skills (empty)

Content URL https://www.myworkday.com/rhahealthservices/e
mail-universal/inst/17815$323/rel-task/2997$109
$1.htmld

Enforce Lesson Order No

C) an ) C Schedule ) C Create Reminder )

httos // www.myworkday.com/rhahealthservices/d/inst/1$17815/17815$323 htmid#TABTASKID=2998% 2440031

12/23/24, 7:45 AM View Blended Course - Workday

Allowed Assessors

Rights of Medication In- 1
Service Sheet
Required
Training Activity
Lesson Rights of Medication In-Service Sh

Lesson Type Training Activity

Lesson Order 1

Required Yes

Lesson Title Rights of Medication In-Service Sheet
Track Attendance Yes

Track Grades Yes

Grading Scheme Pass/Fail

Training Activity Type € )

Training Details upload the in-service training sheet as proof of c complet

on Schedule Create Reminder

hitps://www.myworkday.com/rhahealthservices/d/inst/1$17815/1781 5$323.htmid#TABTASKIL

440031

12/23/24, 7:45 AM View Blended Course - Workday

on Schedule Create Reminder

https://www.myworkday.com/rhahealthservices/d/inst/1$17815/17815$323 htmld#TABTASKID=2998%2440031 3/3

Adachoarit c }
a
In-service Training
Place Held: Start Time: {[o: OOx,

12/19 aca} ry Benson Hise End Time: 5. Hany
Title of Training: b4edication Gene Reports 2 Level 1 Inciolunt Reports

Purpose/Outline of Training:

PY mviewed Procedures oe Lead (= Hed Error wodent 45, discussed reguivecd |
Ame-ko Submit (zihnows)) reviewed Yorn — whe | + (row 40 complete

‘[iforimeck team at OR suste aN d
baht +e Compude ‘rol at Fee RT 7 canylene ot
Attendance

Printed Name Signature Work Location

RHA |

HALIM SERVICES

Date:

‘on Carace. \nlasialouscn _ Bae nite. Ae
Instridctor's Name (printed) Title/Credentials Instructor's Signature

Second Instructor's Name " ~“Title/Credentials ~~Instructor's Signature

Last Modified: 11/07/2012 Form#: 11005

AXRAA

HEALTH SERVICES

In-service Training

Place Held: Start Time: [e:00 am

Mary Benson House End Time: 10: 30anry
* Urine ane Screening ale aad Procechire.

Purpose/Outline of Training:

Title of Trainin

Pu reviewed 3.08 Screenina, Folio and Receduse for Sutcstance
Use Disorder Treatwent Services, rm “Ory Cperakors Wan

eA eek for iniriadt +t sealiue ape. Feel cules

i ‘pre Tm “IW AAating ~ monitoring AE 1S

oo amples. BA resi bused Procedure’ disensa | a stent quick vst dag pice
Attendance

Printed Name

Second Instructor's Name Title/Credentials instructor's Signature

Last Modified: 11/07/2012 Form#: 11005