summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 06/18/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA (2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER: A. BUILDING

(X3) DATE SURVEY
COMPLETED

34G229 B. WING

06/09/2021

4E OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE
584 RIDGE LANE

EABEWSOD: WILKESBORO, NC 28697

4) 1D SUMMARY STATEMENT OF DEFICIENCIES Py PROVIDER'S PLAN OF CORRECTION xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ‘COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE OATE
DEFICIENCY)

a

W 288 | MGMT OF INAPPROPRIATE CLIENT W 288
BEHAVIOR
CFR(s): 483.480(b)(3)

W 288 Qualified Professional
will in-service staff

on managing client
inappropriate behavior and
following the individuals
supported Behavior Support

Techniques to manage inappropriate client
behavior must never be used as a substitute for
an active treatment program.

Plan.
This STANDARD is not met as evidenced by: The clinical team will
Based on observations, record review and follow up weekly with
interviews, the team failed to assure techniques interaction/engagement
fo manage inappropriate behavior were not used assessments for 30 days to
as a substitute for active treatment for 6 of 6 ensure staff are trained and
clients (#1, #2, #3, #4, #5 and #6) relative to observations reveal that acces:
television remote access. The finding is: to television remote is availabl

for active treatment of clients. |
Observations during the 6/8-9/21 survey revealed the future, the Qualified Professional
a television in the living room that various clients will ensure staff are trained in keeping
at various times were observed to sit in the living items in the home accessible.
taom and watch. Continued observation of the
living room area on 6/8-9/21 revealed no remote By July 25, 2021

control to the television.

| Further observation on 6/9/21 at 8:10 AM

| revealed staff B to remove a television remote

| from the kitchen cabinet and to enter the living

| room where client #4 was watching television.

| Subsequent observation revealed staff B to
change the television channel and to engage
cllent #4 in a preferred channel selection.
Additional observation revealed staff B to return
the television remote to the kitchen cabinet after
assisting client #4 with identifying a preferred
channel.

Interview with staff A on 6/9/21 revealed the

television remote is kept in the kitchen cabinet
due to behaviors of some clients with breaking,
losing or hiding the remote control. Continued

(X8) OATE

LABORATORY, 2RECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
fd g the date of survey whether or not a plan of correction |s provided. For nursing homes, the above findings and plans of correction are disclosable 14
da, _dllowing the dale these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2587(02-99) Previous Versions Obsolete Event ID; 0QFX11 Facility ID: 922099 If continuation sheet Page 1 of §

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

PRINTED: 06/48/2021
FORM APPROVED
OMB NO. 0938-0391

‘STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

34G229

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

8. WING

AE OF PROVIDER OR SUPPLIER

LAKEWOOD

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

(x4) 1D
PREFIX
TAG

—

W 288 | Continued From page 1

interview with staff A verified clients #1, #2 and #4
did not have personal televisions in their bedroom
and were dependent on the living room television
to have the ability to watch television. Interview
with the facility qualified intellectual disabilities
professional (QIDP) on 6/9/21 verified the remote
control to the group home living room television
should not be kept in the kitchen cabinet.

DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(1)(2)

W 382

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

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to keep a prescription topical locked for 1 of
3 sampled clients residing in the facility #3). The

finding is:

Observation in the group home on 6/9/21 at 7:55
AM revealed staff A to enter the bedroom of client
#3 and to exit with the client's shower box that
was taken to a hallway bathroom. Continued
observation revealed staff A to leave client #3's
shower box unattended in the bathroom, with the
bathroom door open, and to return to client #3's
room. Observation of the contents of client #3's
shower box revealed a bottle of shampoo with a
prescription label. Subsequent observation
revealed the bathroom door to remain open and
client #3's shower box to sit unattended from 7:59
AM until 8:04 AM.

Review of records for client #3 on 6/9/21 revealed
physician orders dated 5/26/21. Continued

FORM CMS-2567(02-99} Previous Versions Obsolete Event 10: 0QFX11

ID
PREFIX
TAG

W 288

W 382

STREET ADDRESS, CITY, STATE, ZIP CODE
$54 RIDGE LANE
WILKESBORO, NC 28697

(X3) DATE SURVEY
COMPLETED

06/09/2021

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

W 382 - All topical medicatioins have
been relocated and stored properly
in the medication closet.

The LPN and Qualified

Professional will in-service staff on
keeping drugs and biologicals locked
except for when being prepared

for administration. In the future, nursing
will ensure all staff are trained to store|
medication properly in a locked area
when not being administered. Weekly
nursing assessments will be completed
weekly for 30 days.
Administrator will in-service nursing |
team on proper medication storage
and routine follow up. In the future, Niirsing
will ensure that staff are trained in cen

rs

all drugs and biologicals locked, exce
when being prepared for administration.

By July 25, 2021

ae ee ae SO,

Facility 10; 922069

Hf continuation sheet Page 2 of §

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X14) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

«& OF PROVIDER OR SUPPLIER

LAKEWOOD

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

(x4) ID
PREFIX
TAG

W 382

Continued From page 2 |

review of the current physician orders for client #3
revealed an order for Ketoconazole 2% shampoo
with the directive to apply to scalp, leave on 5
minutes before washing; 3 times weekly,

Interview with staff A on 6/9/21 verified client #3
has a prescribed shampoo that is kept in the
client's shower box. Continued interview with
staff A revealed staff are allowed to store
medicated shampoo in the client's shower box
because it is a shampoo and used during
showers. Interview with the facility nurse on
6/9/21 revealed client #3's prescribed shampoo
should not be kept in the clients shower box and
should not be left unattended. Continued
interview with the facility nurse verified a
prescription strength shampoo should be kept
locked in the medication room and the medication
record should be signed when staff administer the
shampoo.

SPACE AND EQUIPMENT

CFR(s): 483.470(g)(2)

W 436

The facility must furnish, maintain in good repair,
and teach clients to use and to make informed j
choices about the use of dentures, eyeglasses,
hearing and other communications aids, braces,
and other devices identified by the
interdisciplinary team as needed by the client.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to provide teaching
relative to eyeglasses for 1 of 3 sampled clients
| G5). The finding is:

—

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

8. WING

PRINTED: 06/48/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/09/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28687

PROVIDER'S PLAN OF CORRECTION xs)
{EACH CORRECTIVE ACTION SHOULD SE ‘COMPLETION

CROSS-REFERENCED TO THE APPROPRIATE ATE:

DEFICIENCY)

PREFIX
TAG

W436) W436 - Habilitation Specialists will

collaborate training objective for
formal programming for care of person
supported eyewear. Formal
programming will be implemented
to train client on care and maintenance
of eyewear. Clinical team will complete
interaction assessments once weekl
for 30 days to monitor new program
progress.
In the future, formal programming will
continue as client progresses to i
achieve objective. |

By July 25, 2021

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QFX11

Facility 1D: 922098 If continuation sheat Page 3 of 5

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

W 436

FORM CMS-2587(02-99) Previous Versions Obsolete

STATEMENT Of DEFICIENCIES
AND PLAN OF CORRECTION

(%1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER;

34G229

4a& OF PROVIDER OR SUPPLIER

LAKEWOOD

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

Continued From page 3

Observation in the group home throughout the
6/8-9/21 survey revealed client #5 to participate in
various activities to include: leisure activities at
the dining table, setting the table for the dinner
meal, meal participation, household chores and
medication administration. Continued
observations throughout the 6/8-9/21 survey
tevealed client #5 to participate in activities
without the use of eyeglasses. Subsequent
observation revealed no prompts or direction
from staff for client #5 to wear eyeglasses.

Review of records for client #5 on 6/9/21 revealed
a person centered plan (PCP) dated 12/16/20
with training objectives relative to learning to use
a check register, make bed, privacy, brush teeth
and wash hands. Continued review of records for
client #5 revealed a behavior plan for target
behaviors of physical aggression, taking items
that belong to others, food snatching, verbal
aggression, false accusations, un-cooperation,
inappropriate touch, property destruction,
hyperactive behavior and depressed behavior.
Property destruction was defined as throwing
items, breaking items, hitting/kicking items or any
other attempt to destroy the environment.

Review of a vision consult for client #5 dated
5/7/19 revealed a diagnosis of myopia and
astigmatism. Further review of the current vision
consult revealed the recommendation to initiate
glasses to improve vision

interview with client #5 on 6/8/21 revealed she
had broke her eyeglasses and had new glasses
on order. Interview with facility staff verified client
#5 had broken her eyeglasses in her sleep and
new eyewear had been ordered. Continued
interview with facility staff verified client #5 has a

Event ID: 00F x11

(X2) MULTIPLE CONSTRUCTION

A. BUILDING __

8. WING

1D
PREFIX
TAG

es |

|
}

W 436

Facility 1D: 622099

STREET ADORESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

|(X3) DATE SURVEY
COMPLETED

06/09/2021

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

\f continuation sheet Page 4 of 5

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

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

434G229

B. \MNG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

aE OF PROVIDER OR SUPPLIER

STREET ADORESS, CITY, STATE, ZIP CODE
54 RIDGE LANE
WILKESBORO, NC 28697

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

W 436 | Continued From page 4
| history of breaking her eyeglasses as she will
| throw them, sleep in them and is really rough with
| care.

Interview with the facility qualified intellectual
disabilities professional (QIDP) verified client #5
has a history of breaking her eyeglasses due to
improper care. Continued interview with the
QIDP verified client #5 did not have a training
objective to address proper care of eyeglasses.
Subsequent interview with the QIDP revealed
client #5 could benefit from a program to address
proper care of her eyewear and it was unknown
why a program had not been implemented.

10
PREFIX
TAG

DEFICIENCY)

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

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/09/2021

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID: 0QF x15

Facility ID: 922090

If continuation sheet Page 5 of 5

document_type: Plan of Correction


state: NC

facility_name: Lakewood

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 09/05/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
34G229 B.WING 08/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
Arevisit was conducted on 8/30/19 for all
previous deficiencies cited on 6/25/19. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:80xG12 Facility ID: 922099 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 06/26/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
34G229 B.WING_ 06/25/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
LAKEWOOD WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID | PROVIDER'S PLAN OF CORRECTION | (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 247 | INDIVIDUAL PROGRAM PLAN W 247) yy 247 QP will complete in-service with staffon| 8-16-2019
| CFR(s): 483.440(c)(6)(vi) the importance of people supported participating
in meal preparation with all meals. The clinical
The individual program plan must include team will complete mealtime assessments two
opportunities for client choice and times a week for a period of one month and then

on a routine basis. In the future, the QIDP will

| seffmanagement. ensure staff are providing opportunities for
This STANDARD is not met as evidenced by: choice and independence relative to meal pre-

| Based on observation, record review and ; paration and service.
| interview, the facility failed to assure 5 of 6 clients
in the home (#1, #2, #3, #4, and #5) were
provided opportunities for choice and self
management relative to breakfast meal
preparation. The finding is:

Observations on 6/25/19 at 6:15 AM, upon
entering the group home, revealed one staff
person was in the home and all clients were still
in their bedrooms except for client #3 who was in
the bathroom. Continued observations in the
| kitchen area revealed prepared bran muffins
covered in a serving bowl, a full pot of coffee and
cantaloupe pieces cut into bite size pieces ina RECEIVED
plastic container. Review of the breakfast menu
for 6/25/19 revealed bran muffins, cantaloupe,
orange juice, coffee and milk. Interview with staff JUL 12 2019
| B on 6/25/19 confirmed she had prepared all
breakfast items.

| DHSRNHL&C
Review of the records for clients #1, #2, #3, #4 Black Mountain / WRO
and #5 on 6/25/19 revealed all clients had a
_ current person centered plan and adaptive
behavior inventories (ABI) completed within the
past year. Review of the ABI's for all five clients
indicated they were fully independent and/or
partially independent with multiple areas related
to meal preparation tasks.

Interview with the qualified intellectual disabilities
professional (QIDP) on 6/25/19 confirmed clients |
#1, #2, #3, #4 and #65 are all capable of

LABORATOR t PIBECTOR'S: OR PROVIDER/SWPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

.
fp 4
g LAY Dey na AL Fee Srna fA wd addy KL4
Any deficiency statement engjhg with an asterisk (*) denotes a Péfciency which the institutldn may be excised from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See Instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14.
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite ta continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11 Facility ID: 22099 If continuation sheet Page 1 of 3

PRINTED: 06/26/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERI/CLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

B. WING

34G229 06/25/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY) |
= — Sue
W 247 | Continued From page 1 W 247

participating with meal preparation tasks with at
least partial independence. The QIDP also
confirmed that the clients should have been
offered the opportunity of choice and self
management by assisting with the breakfast meal
preparation on 6/25/19.

W 369) DRUG ADMINISTRATION W 369 . , :
, W 369 The nurse will complete in-service train-
CFR(s): 483.460(k)(2) ing on the proper way to administer liquid med-| 8-16-2018
. . | ications which is to use a syringe. The clinical
The system for drug administration must assure team will monitor medication administration two,
that all drugs, including those that are | times a week for one month then on a routine
self-administered, are administered without error, basis. In the future, QIDP will ensure staff are

properly trained on medication administration.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility's system for drug
administration failed to assure all drugs were
administered without error for 1 of 2 clients
observed during drug administration (#1). The
finding is:

Observations conducted on 6/25/19 at 8:14 AM
| revealed client #1 to be prompted by staff C to
enter the medication administration room where
she was assisted by staff C to receive |
medications including Cogentin 2mg-one tablet,
Loestrin 1/35-one tablet, Prozac 40mg-one tablet,
Topomax 50mg-one tablet, Geodon 40mg-one

| tablet and Haldol concentrate liquid
(2mg/ml)-.05ml via oral syringe.

Review of the record for client #1 on 6/25/19
revealed physicians orders dated 6-6-19. The
orders included Haldol concentrate liquid
(2mg/ml), give .6ml (1mg) by mouth each
morning.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11 Facility ID: 922099 If continuation sheet Page 2 of 3

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

PRINTED: 06/26/2019
FORM APPROVED
OMB NO. 0938-03914

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
34G229 8. WING 06/25/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

Interview with the facility nurse on 6/25/19
confirmed client #1 should receive Haldol
concentrate liquid (2mg/ml), .5ml (14mg) by mouth
during the morning medication administration on
6/25/19 as ordered by the physician.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11

LAKEWOOD
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
W 369 | Continued From page 2 W 369

Facility ID: 922099

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

DEFICIENCY)

(x5)
COMPLETION
DATE

If continuation sheet Page 3 of 3

inspection_type: MHLCS Annual


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 06/26/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER: ‘A. BUILDING

34G229 B. WING 06/25/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 247 | INDIVIDUAL PROGRAM PLAN W 247

CFR(s): 483.440(c)(6)(vi)

The individual program plan must include
opportunities for client choice and
self-management.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to assure 5 of 6 clients
in the home (#1, #2, #3, #4, and #5) were
provided opportunities for choice and self
management relative to breakfast meal
preparation. The finding is:

Observations on 6/25/19 at 6:15 AM, upon
entering the group home, revealed one staff
person was in the home and all clients were still
in their bedrooms except for client #3 who was in
the bathroom. Continued observations in the
kitchen area revealed prepared bran muffins
covered in a serving bowl, a full pot of coffee and
cantaloupe pieces cut into bite size pieces in a
plastic container. Review of the breakfast menu
for 6/25/19 revealed bran muffins, cantaloupe,
orange juice, coffee and milk. Interview with staff
B on 6/25/19 confirmed she had prepared all
breakfast items.

Review of the records for clients #1, #2, #3, #4
and #5 on 6/25/19 revealed all clients had a
current person centered plan and adaptive
behavior inventories (ABI) completed within the
past year. Review of the ABI's for all five clients
indicated they were fully independent and/or
partially independent with multiple areas related
to meal preparation tasks.

Interview with the qualified intellectual disabilities
professional (QIDP) on 6/25/19 confirmed clients
#1, #2, #3, #4 and #5 are all capable of

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11 Facility ID: 922099 If continuation sheet Page 1 of 3

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

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

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 06/26/2019
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED
B.WING 06/25/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

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

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility's system for drug
administration failed to assure all drugs were
administered without error for 1 of 2 clients
observed during drug administration (#1). The
finding is:

Observations conducted on 6/25/19 at 8:14 AM
revealed client #1 to be prompted by staff C to
enter the medication administration room where
she was assisted by staff C to receive
medications including Cogentin 2mg-one tablet,
Loestrin 1/35-one tablet, Prozac 40mg-one tablet,
Topomax 50mg-one tablet, Geodon 40mg-one
tablet and Haldol concentrate liquid
(2mg/ml)-.05ml via oral syringe.

Review of the record for client #1 on 6/25/19
revealed physicians orders dated 6-6-19. The
orders included Haldol concentrate liquid
(2mg/ml), give .5ml (1mg) by mouth each
morning.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 247 | Continued From page 1 W 247
participating with meal preparation tasks with at
least partial independence. The QIDP also
confirmed that the clients should have been
offered the opportunity of choice and self
management by assisting with the breakfast meal
preparation on 6/25/19.
W 369 | DRUG ADMINISTRATION W 369

Facility ID: 922099 If continuation

sheet Page 2 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 06/26/2019
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

(X3) DATE SURVEY
COMPLETED

06/25/2019

Interview with the facility nurse on 6/25/19
confirmed client #1 should receive Haldol
concentrate liquid (2mg/ml), .5ml (1mg) by mouth
during the morning medication administration on
6/25/19 as ordered by the physician.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 80XG11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 369 | Continued From page 2 W 369

Facility ID: 922099

If continuation sheet Page 3 of 3


raw_content:
PRINTED: 08/10/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346229 08/09/2018

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

LAKEWOOD
WILKESBORO, NC 28697

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

A revisit survey was conducted on 8/9/18 for all
previous deficiencies cited on 6/6/18. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:IE7N12 Facility ID: 922099 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 06/08/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER: ‘A. BUILDING

(X3) DATE SURVEY
COMPLETED

B. WING

34G229 06/06/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWooD 554 RIDGE LANE
WILKESBORO, NC 28697

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES.

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

W 153 | STAFF TREATMENT OF CLIENTS W 153
CFR(s): 483.420(d)(2)

The facility must ensure that all allegations of
mistreatment, neglect or abuse, as well as
injuries of unknown source, are reported
immediately to the administrator or to other
officials in accordance with State law through
established procedures.

This STANDARD is not met as evidenced by:
Based on facility document review and interview,
the facility failed to ensure all allegations of
potential abuse/neglect were reported to the
administrator immediately for 1 of 1 investigations
reviewed. The finding is:

Review of the facility's abuse/neglect
investigations on 6/5/18 revealed an investigation
started on 10/10/17 and completed on 10/13/17.
Review of the investigation revealed on 10/10/17
at 4:30 PM, the qualified intellectual disabilities
professional (QIDP) received a call from the local
department of social services (DSS) advising they
had started an abuse allegation investigation
because they had received a report of staff to
client physical abuse. Continued review of the
facility investigation revealed the facility started an
investigation on 10/10/17 to determine if Staff A
and/or Staff B had pinched or pulled the hair of
client #1. Further review of the facility
investigation revealed DSS received a report
related to Staff A abusing client #1 and during the
process of the facility investigation another
allegation developed related to Staff B abusing
client #1. Both staff members were suspended
immediately. The facility investigation did not
result in a finding of abuse or mistreatment.

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11 Facility ID: 922099 If continuation sheet Page 1 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

PRINTED: 06/08/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/06/2018

NAME OF PROVIDER OR SUPPLIER
LAKEWOOD

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

(X4) ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

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

ID
PREFIX
TAG

(x5)
COMPLETION
DATE

W 153 | Continued From page 1

Continued review of the facility investigation
documentation revealed an incident/accident
report completed on 10/10/18 for an incident
which occurred on 10/9/18 at 7:00 AM. The
incident/accident report indicated that while
assisting client #1 with bathing and dressing, a
direct care staff person discovered a bruising on
client #1's upper right arm. The report
documentation revealed the direct care staff
person asked the client how the bruising occurred
and the client indicated "staff did it, but gave no
name." Continued review of the report
documentation revealed the home manager was
notified on 10/9/18 and no other staff notifications
were documented.

Interview with the qualified intellectual disabilities
professional and the facility administrator on
6/6/14 confirmed they were first made aware of
the allegation when DSS called the facility to
report the start of their investigation. Therefore,
the staff failed to immediately report an allegation
of abuse to the facility administrator resulting in a
one day delay in the start of the investigation.
NURSING SERVICES

CFR(s): 483.460(c)

W 331

The facility must provide clients with nursing
services in accordance with their needs.

This STANDARD is not met as evidenced by:
Based on observation, facility document review
and interview, nursing services failed to assure
staff were adequately trained to notify nursing of
client incidents/injuries in a timely manner for 2 of
3 sampled clients (#1 and #6). The findings are:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11

W 153

W 331

Facility ID: 922099 If continuation

sheet Page 2 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 06/08/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

06/06/2018

A. Nursing services failed to assure direct care
staff were adequately trained to notify nursing of a
bruised area for client #1. Examples include:

Review of facility incident reports on 6/5/18
revealed an incident report completed on
10/10/17 for bruising on client #1's upper right
arm which was discovered on 10/9/17 at 7:00
AM. Review of the incident/accident report
documentation revealed direct care staff
discovered the bruising while assisting the client
with bathing/dressing. Continued review of the
incident report did not indicate nursing services
was notified until 10/10/17. Further review of the
report revealed nursing assessed the client on
10/10/17 and the nursing documentation
indicated two small bruises on the client's upper
right arm area. This incident report was also
included as part of a facility abuse/neglect
investigation documentation.

Interview with nursing staff on 6/6/18 confirmed
that nursing services was not notified of this injury
until 10/10/18 and confirmed group home staff
should have notified nursing services immediately
following the discovery of the injury.

B. Nursing services failed to assure direct care
staff were adequately trained to notify nursing of
an incident with potential injury for client #6.

Observations conducted on 6/5/18 at 4:45 PM
revealed client #6 was seated at a table on the
outdoor patio of the home. Continued
observations revealed client #6 completed a craft
project which included painting a wooden "tulip".
Client #6 was subsequently observed to take the
tulip to place it in the yard of the home,
accompanied by staff holding his gait belt. Client

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 2 W 331

Facility ID: 922099

If continuation sheet Page 3 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER
LAKEWOOD

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

(X4) ID
PREFIX
TAG

PRINTED: 06/08/2018
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED
B.WING 06/06/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

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

ID
PREFIX
TAG

(x5)
COMPLETION
DATE

W 331 | Continued From page 3

#6 was then observed to drop forcefully to his
knees on the concrete patio while placing the
wooding tulip in an adjacent flower bed.

Interview conducted on 6/6/18 with the nurse
revealed client #6 has been identified as having
an increased risk of falls for which the use of a
gait belt has been implemented. Further
interview with the nurse revealed no notification
or written documentation had been received
regarding the incident which occurred on 6/5/18
during which client #6 dropped to his knees on
the patio. Continued interview with the nurse
verified all incidents involving falls and/or actual
or potential injury to client #6 should be
documented and reported to the nurse.

DRUG ADMINISTRATION

CFR(s): 483.460(k)(6)

W 373

The system for drug administration must assure
hat no client self-administers medication until he
or she demonstrates the competency to do so.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the system for drug administration
failed to assure 1 of 3 sampled clients did not
self-administer medication until demonstrating the
competency to do so (client #5). The finding is:

Observations conducted on 6/6/18 at 8:15 AM
revealed client #5 emerging from the medication
administration area carrying a plastic medication
cup containing a liquid substance in her hand.
Client #5 was then observed to walk
unsupervised toward her bedroom with the cup
and immediately return to the living room of the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11

W 331

W 373

Facility ID: 922099 If continuation

sheet Page 4 of 6

DEPARTMENT OF HEA\

LTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G229

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

PRINTED: 06/08/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/06/2018

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

home and toss the cup into the trash. Staff was

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 373 | Continued From page 4 W 373

then observed
the medication
had spilled it in
observed to en

stated client #5'
direct care stai
substance in thi
(Chlorhexidine

medications to

io ask client #5 what happened to
in the cup and client #5 stated she
her bedroom. Staff was then

er client #5's bedroom and state

they were unable to locate a spill, however, staff

's toothbrush was found in the

trash receptacle in her bedroom. Interview with

at that time revealed the liquid
ie medication cup was Peridex
glucconate) solution that client #5

had been given by staff administering

brush her teeth with. Subsequent

observations ai

8:20 AM revealed the home

manager replaced the Chlorhexidine glucconate
solution and toothbrush for client #5 and
accompanied client #5 to the bathroom to brush
her teeth.

Review of the record for client #5, conducted on
6/6/18, revealed physician's orders dated 4/10/18
documenting client #5 was to receive
Chlorhexidine glucconate 0.12% - brush to teeth
twice daily for gingivitis. Further review of the
record for client #5 revealed a person centered
plan (PCP) dated 2/23/18 which included training
objectives for client #5 including: fill out a check,
improve work behaviors, make bed, rinse hair,
ensure privacy and decrease target behaviors.
Continued review of the 2/23/18 PCP revealed an
adaptive behavior inventory (ABI) dated 1/17/18
which documented client #5 demonstrated no
independence to partial independence in any
area of self-administration of medications.

Interview with the home manager present in the
home throughout survey observations on the
morning of 6/6/18 verified client #5 had been
provided with the liquid medication in the cup

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11

Facility ID: 922099 If continuation

sheet Page 5 of 6

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

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

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 06/08/2018

FO!

RM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED
B.WING 06/06/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

which was identified as Peridex (Chlorhexidine
glucconate) solution by direct care staff
administering medications, and given instruction
to take the Peridex to the bathroom and brush
her teeth with it. Interview conducted with the
nurse on 6/6/18 at 11:30 AM further verified client
#5 had a current physician's order for
Chlorhexidine glucconate 0.12% to brush her
teeth with twice daily. This interview further
revealed client #5 had not demonstrated
competency in self-administration of medications.
This interview further verified staff administering
medications should supervise and assist client #5
during all aspects of medication administration.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IE7N11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 373 | Continued From page 5 W 373

Facility ID: 922099

If continuation sheet Page 6 of 6


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 06/08/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES ORM ABPROAED

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

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

34G229 B, WING

06/06/2018

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

WILKESBORO, NC 28697

LAKEWOOD

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
T nee, as
W 153| STAFF TREATMENT OF CLIENTS W 153 ‘bee
CFR(s): 483.420(d)(2) The Qualified Professional will

in-service staff on RHA Policy for

The facility must ensure that all allegations of Reporting Abuse/Neglect/Exploitation.

mistreatment, neglect or abuse, as well as The Administrator will monitor all Incident
injuries of unknown source, are reported Reports and investigations as they occur tq
immediately to the administrator or to other ensure the Policy for Abuse/Neglect/
officials in accordance with State law through Exploitation is followed timely. In the futu
established procedures. the Qualified Professional will ensure sat |
are trained on who to report Abuse/Neglect

Exploitation to and timely reporting.

This STANDARD is not met as evidenced by: By: July 20, 2018
Based on facility document review and interview,
the facility failed to ensure all allegations of
potential abuse/neglect were reported to the
administrator immediately for 1 of 1 investigations
reviewed. The finding is:

Review of the facility's abuse/neglect
investigations on 6/5/18 revealed an investigation
started on 10/10/17 and completed on 10/13/17.
Review of the investigation revealed on 10/10/17
at 4:30 PM, the qualified intellectual disabilities
professional (QIDP) received a call from the local
department of social services (DSS) advising they
had started an abuse allegation investigation
because they had received a report of staff to
client physical abuse. Continued review of the
facility investigation revealed the facility started an
investigation on 10/10/17 to determine if Staff A
and/or Staff B had pinched or pulled the hair of
client #1. Further review of the facility
investigation revealed DSS received a report
telated to Staff A abusing client #1 and during the
process of the facility investigation another
allegation developed related to Staff B abusing
client #1. Both staff members were suspended
immediately. The facility investigation did not
result in a finding of abuse or mistreatment.

LABORATORY DIRECTOR'S OR PROV

/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
: .

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

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID:IE7N14 Facility ID: 922099 If continuation sheet Page 1 of 6

|
|

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X14) PROVIDER/SUPPLIER/CLIA,
IDENTIFICATION NUMBER:

34G229

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

B. WING

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL

TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
W 153} Continued From page 1

W 331

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

Continued review of the facility investigation
documentation revealed an incident/accident
report completed on 10/10/18 for an incident
which occurred on 10/9/18 at 7:00 AM. The
incident/accident report indicated that while
assisting client #1 with bathing and dressing, a
direct care staff person discovered a bruising on
client #1's upper right arm. The report
documentation revealed the direct care staff
person asked the client how the bruising occurred
and the client indicated "staff did it, but gave no
name." Continued review of the report
documentation revealed the home manager was
notified on 10/9/18 and no other staff notifications
were documented.

Interview with the qualified intellectual disabilities
professional and the facility administrator on
6/6/14 confirmed they were first made aware of
the allegation when DSS called the facility to
report the start of their investigation. Therefore,
the staff failed to immediately report an allegation
of abuse to the facility administrator resulting in a
one day delay in the start of the investigation.
NURSING SERVICES

CFR(s): 483.460(c)

The facility must provide clients with nursing
services in accordance with their needs.

This STANDARD is not met as evidenced by:
Based on observation, facility document review
and interview, nursing services failed to assure
staff were adequately trained to notify nursing of
client incidents/injuries in a timely manner for 2 of
3 sampled clients (#1 and #6). The findings are:

Event ID1E7N14

PREFIX
TAG

W 153

W 331

Facility ID: 922099

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 06/08/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/06/2018

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION

CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Aleohe

If continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 06/08/2018

FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A, BUILDING COMPLETED
34G229 8, WING

06/06/2018

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

LAKEWOOD

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

W 331 | Continued From page 2 W 331

A. Nursing services failed to assure direct care The LPN and Qualified Professional will in-

staff were adequately trained to notify nursing of a service staff on Incident/Accident Reporting

bruised area for client #1. Examples include: and notifications. The Qualified Professional
and Administrator will monitor all incident

Review of facility incident reports on 6/5/18 cere tiecly ond to ensure they are

revealed an incident report completed on made. In the future the Qualified Professional

10/10/17 for bruising on client #1's upper right will ensure staff are trained on completing

arm which was discovered on 10/9/17 at 7:00 Incident Reports and making the appropriate

AM. Review of the incident/accident report notifications.

documentation revealed direct care staff

discovered the bruising while assisting the client By: July 20, 2018

with bathing/dressing. Continued review of the
incident report did not indicate nursing services
was notified until 10/10/17. Further review of the
report revealed nursing assessed the client on
10/10/17 and the nursing documentation
indicated two small bruises on the client's upper
right arm area. This incident report was also
included as part of a facility abuse/neglect
investigation documentation.

Interview with nursing staff on 6/6/18 confirmed
that nursing services was not notified of this injury
until 10/10/18 and confirmed group home staff
should have notified nursing services immediately
following the discovery of the injury.

B. Nursing services failed to assure direct care
staff were adequately trained to notify nursing of
an incident with potential injury for client #6.

Observations conducted on 6/5/18 at 4:45 PM
revealed client #6 was seated at a table on the
outdoor patio of the home. Continued
observations revealed client #6 completed a craft
project which included painting a wooden "tulip".
Client #6 was subsequently observed to take the
tulip to place it in the yard of the home,
accompanied by staff holding his gait belt. Client

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID:1E7N11 Facility ID: 922099 If continuation sheet Page 3 of 6

PI 2
DEPARTMENT OF HEALTH AND HUMAN SERVICES RO ORM APPROVED

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

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

346229 B, WING

—_—_—_——————____— 06/06/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
LAKEWOOD WILKESBORO, NC 28697
x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
ee
W 331 | Continued From page 3 W 331
#6 was then observed to drop forcefully to his
knees on the concrete patio while placing the
wooding tulip in an adjacent flower bed.
Interview conducted on 6/6/18 with the nurse
revealed client #6 has been identified as having
an increased risk of falls for which the use of a
gait belt has been implemented. Further
interview with the nurse revealed no notification
or written documentation had been received
regarding the incident which occurred on 6/5/18
during which client #6 dropped to his knees on
the patio. Continued interview with the nurse
verified all incidents involving falls and/or actual
or potential injury to client #6 should be
documented and reported to the nurse.
W 373 | DRUG ADMINISTRATION W 373 ana , .
The LPN will in-service staff on client #5 need
CFR(s): 483.460(k)(6) for supervision during Medication
Administration. The clinical team will monitor
The system for drug administration must assure 2x a week for 1 month then on routine basis
that no client self-administers medication until he through Medication Observations to ensure
or she demonstrates the competency to do so. staff are providing supervision for client #5

during Medication Administration. In the
future nursing will ensure staff are trained on
. . . client specific ABI's and the determination bi

This STANDARD 's not met as evidenced by: the team on client's independence or level ct
Based on observation, record review and supervision during Medication Administration.
interview, the system for drug administration

failed to assure 1 of 3 sampled clients did not By: July 20, 2018

self-administer medication until demonstrating the
competency to do so (client #5). The finding is:

Observations conducted on 6/6/18 at 8:15 AM
revealed client #5 emerging from the medication
administration area carrying a plastic medication
cup containing a liquid substance in her hand.
Client #5 was then observed to walk
unsupervised toward her bedroom with the cup
and immediately return to the living room of the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:1E7N11 Facility ID: 922098 If continuation sheet Page 4 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRN ORM A oeot8

FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

346228 B.WING 06/06/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
LAKEWOOD

WILKESBORO, NC 28697
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION

(x6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

a

W 373 | Continued From page 4 W 373

home and toss the cup into the trash. Staff was
then observed to ask client #5 what happened to
the medication in the cup and client #5 stated she
had spilled it in her bedroom. Staff was then
observed to enter client #5's bedroom and state
they were unable to locate a spill, however, staff
stated client #5's toothbrush was found in the
trash receptacle in her bedroom. Interview with
direct care staff at that time revealed the liquid
substance in the medication cup was Peridex
(Chlorhexidine glucconate) solution that client #5
had been given by staff administering
medications to brush her teeth with. Subsequent
observations at 8:20 AM revealed the home
manager replaced the Chlorhexidine glucconate
solution and toothbrush for client #5 and
accompanied client #5 to the bathroom to brush
her teeth.

Review of the record for client #5, conducted on
6/6/18, revealed physician's orders dated 4/10/18
documenting client #5 was to receive
Chlorhexidine glucconate 0.12% - brush to teeth
twice daily for gingivitis. Further review of the
record for client #5 revealed a person centered
plan (PCP) dated 2/23/18 which included training
objectives for client #5 including: fill out a check,
improve work behaviors, make bed, rinse hair,
ensure privacy and decrease target behaviors.
Continued review of the 2/23/18 PCP revealed an
adaptive behavior inventory (ABI) dated 1/17/18
which documented client #5 demonstrated no
independence to partial independence in any
area of self-administration of medications.

Interview with the home manager present in the
home throughout survey observations on the
morning of 6/6/18 verified client #5 had been
provided with the liquid medication in the cup

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID:IE7N11 Facility ID: 922099 if continuation sheet Page 5 of 6

PRINTED: 06/08/2018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO, 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
34G229 B.WING 06/06/2018

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

WILKESBORO, NC 28697

LAKEWOOD

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

W 373 | Continued From page 5 W 373

which was identified as Peridex (Chlorhexidine
glucconate) solution by direct care staff
administering medications, and given instruction
to take the Peridex to the bathroom and brush
her teeth with it. Interview conducted with the
nurse on 6/6/18 at 11:30 AM further verified client
#5 had a current physician's order for
Chlorhexidine glucconate 0.12% to brush her
teeth with twice daily. This interview further
revealed client #5 had not demonstrated
competency in self-administration of medications.
This interview further verified staff administering
medications should supervise and assist client #5
during all aspects of medication administration.

FORM CMS-2567(02-99) Previous Versions Obsolete Event IDIE7N11 Facility 1D: 922099 If continuation sheet Page 6 of 6


facility_name: Next Level Family Solutions  LLC

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL0601553

NAME OF PROVIDER OR SUPPLIER

NEXT LEVEL FAMILY SOLUTIONS, LLC

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
11128 OLDE ENGLISH DRIVE
CHARLOTTE, NC 28216

FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/24/2025

Acomplaint survey was completed on 2/24/25.
The complaint was unsubstantiated (intake
#NC00225945). No deficiencies were cited.

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

This facility is licensed for 3 and has a current
census of 2. The survey sample consisted of
audits of 1 former client.

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

STATE FORM

6899

22C711

TITLE

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

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
PRINTED: 01/06/2025
FORM APPROVED

Division of Health Service Requlation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

(x3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL0601553 01/03/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

11128 OLDE ENGLISH DRIVE
CHARLOTTE, NC 28216

NAME OF PROVIDER OR SUPPLIER

NEXT LEVEL FAMILY SOLUTIONS, LLC

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
Tas | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE
DEFICIENCY)

V 000 INITIAL COMMENTS

An annual and complaint survey was completed
on 1-3-25. The complaint was unsubstantiated
| (#NC0022359). Deficiencies were cited.

This facility is licensed for the following service
| category: 10A NCAC 27G 5600B Supervised RECEIVED |

| Living for Minors with a Developmental Disability. e
13 202
| This facility is licensed for 3 cand currently has a J AN ,
census of 2. The survey sample consisted of Licensure Sect
| audits of 2 current clients. DHSR-MH

y 114) 27G .0207 Emergency Plans and Supplies Vv114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Each facility shall develop a written fire plan
and a disaster plan and shall make a copy of
these plans available

to the county emergency services agencies upon

Fire and disaster drills will be conducted monthly at least
‘one time per shift (weekdays 7am-3pm, 1

request. The plans shall include evacuation 3pm-11pm & 11pm-7am) and

procedures and routes. {weekends 7am-7pm & 7pm-7am) per month. 3-3-25
5 NFLS will put in place a policy that fire and disaster

(b) The plans shall be made available to all staff drills are completed by the 25th of each month |

and evacuation procedures and routes shall be Fire and disaster drills will be reviewed on a monthly

basis by QP and/or Director to ensure compliance of policy.

posted in the
facility.

(c) Fire and disaster drills in a 24-hour facility |
shall be held at least quarterly and shall be
repeated for each shift.

Drills shall be conducted under conditions that
simulate the facility's response to fire
emergencies.

(d) Each facility shall have a first aid kit
accessible for use.

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

STATE FORM SN8W11 if continuation sheet 1 of 4

‘TITLE DP rectay vo oatt Of - OB-2F

PRINTED: 01/06/2025
FORM APPROVED

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

01/03/2025

MHL0601553

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
11128 OLDE ENGLISH DRIVE
CHARLOTTE, NC 28216

NEXT LEVEL FAMILY SOLUTIONS, LLG

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

DEFICIENCY)

T
Continued From page 1

This Rule is not met as evidenced by:
Based on record review and interview the facility
failed to ensure that fire and disaster drills were

| held at least quarterly on each shift. The findings
| are:

Interview on 1-3-25 with the Director revealed
-During the week there are three shifts,

7am-3pm, 3pm-11pm, and 11pm-7am. |
-On the weekends the shifts were 7am-7pm

and 7pm-7am.

Record review on 1-3-25 revealed:
-No third shift fire drill for the first quarter of
2024.
-No fire drills on second or third shift for the
third quarter of 2024.
-No first or second shift fire drill for the fourth
quarter of 2024. |
-No disaster drills for the third or fourth
quarter for 2024.

Clients #1 and #2 could not be interviewed due to
both being non verbal.

Interview on 1-3-25 with the Director revealed:
-She would ensure that going forward, all

drills would be completed and documented

appropriately.

27E .0101 Client Rights - Least Restrictive
Alternative

| 10A NCAC 27E .0101 LEAST RESTRICTIVE |
ALTERNATIVE |
(a) Each facility shall provide services/supports

Division of Health Service Regulation
STATE FORM eee SNBW11 If continuation sheet 2 of 4

PRINTED: 01/06/2025
FORM APPROVED

Division of Health Service Regulation

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

(3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

B. WING

01/03/2025

MHL0601553

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE
11128 OLDE ENGLISH DRIVE

CHARLOTTE, NC 28216
SUMMARY STATEMENT OF DEFICIENCIES | ID | PROVIDER'S PLAN OF CORRECTION | 5)

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE
DATE

NEXT LEVEL FAMILY SOLUTIONS, LLC

(X4) ID
PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Continued From page 2

that promote a safe and respectful environment.
These include:

i ‘ct II locking systems have been removed
(1) using the least restrictive and most 4 ‘ | 3-3-25
. | tom the refrigerator, drawers and cabinets. |
appropriate settings and. methods: t ngoing supervision of this will be monitored
(2) promoting coping and engagement y QP and/or Director.

skills that are alternatives to injurious behavior to
self or others;

| (3) providing choices of activities
| meaningful to the clients served/supported; and
(4) sharing of control over decisions with |

the clientvlegally responsible person and staff.
| () The use of a restrictive intervention |
procedure designed to reduce a behavior shall

always be accompanied by actions designed to | |
insure dignity and respect during and after the
intervention. These include: |

(1) using the intervention as a last resort;
and
(2) employing the intervention by people

trained in its use.

This Rule is not met as evidenced by:
Based on observation, interview and record |
review the facility failed to provide the least
restrictive and most appropriate setting effecting
2 of 2 clients ( Client #1 and Client #2). The
| findings are:

Review on 1-3-25 of Client #1's record revealed:
-Admitted 2-9-24.
-10 years old.
-Diagnoses of Down Syndrome and Autism
-No documented reason for her having the
refrigerator, kitchen cabinets, of her dresser
drawers locked.

Division of Health Service Regulation
STATE FORM 089 SNeW11 Ifcontinuation sheet 3 of 4

PRINTED: 01/06/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

B.WING

01/03/2025

MHL0601553

STREET ADORESS, CITY, STATE, ZIP CODE
11128 OLDE ENGLISH DRIVE
CHARLOTTE, NC 28216

SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION (x5)

NAME OF PROVIDER OR SUPPLIER

NEXT LEVEL FAMILY SOLUTIONS, LLC

(X4) ID |
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 513) Continued From page 3

Review on 1-3-25 of Client #2's record revealed:

-Admitted 8-12-24.

-16 years old.

-Diagnoses of Autism and Intellectual
Developmental Disability.

-No documented reason for her having the
refrigerator and kitchen cabinets locked.

Observation on 1-3-25 at approximately 1:00pm
revealed:

-Refrigerator in the kitchen with plastic |
locking system on it and the refrigerator was
locked

-Several cabinets in the kitchen had plastic
locking system on them and they were locked.

-Client #1's bedroom, both dressers had
plastic locking system on the drawers and both of
the dressers were locked.

Client #1 and Client #2 were unable to be
interviewed due to both clients being nonverbal.

Interview on 1-3-25 with the Director revealed:
-The locks were placed for another client that |
no longer lived at the facility.
-That client would sometimes empty her |
drawers and put the items on the floor.
-That client would also go into the kitchen
cabinets.
-She would make sure the locks were taken
off of the dresser, refrigerator, and the cabinets.

Division of Health Service Regulation
STATE FORM 6009 SNew11 If continuation sheat 4 of 4

inspection_type: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint


facility_name: Burkwell

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

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHL014-006

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/19/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

3476 MORGANTON BOULEVARD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
02/13/2026

A complaint and follow up survey was completed
on February 13, 2026. The complaint was
substantiated (Intake #NC00235833). No
deficiencies were cited.

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

This facility is licensed for 8 and has a current
census of 7. The survey sample consisted of
audits of 1 former client.

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

STATE FORM

6899

GBZG11

TITLE

BURKWELL
LENOIR, NC 28645
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up


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

raw_content:
PRINTED: 08/21/2025
FORM APPROVED

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

R
MHL014-006 B. WING ____ 08/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD.

BURKWEEL LENOIR, NC 28645
(xa 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 | voo0
| An annual and follow up survey was completed
on August 14, 2025. A deficiency was 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 8 and currently has a |
| census of 8. The survey sample consisted of
audits of 3 current clients.
V 736 27G .0303(c) Facility and Grounds Maintenance | V 736 Doors have been added to all bedrooms 8/15/2025
that were missing doors. Agency
10A NCAC 27G .0303 LOCATION AND currently gathering quotes to replace all
EXTERIOR REQUIREMENTS | bedroom doors to ensure safety.
(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 manner. The
findings are: | |

Observation on 8/12/25 at 12:50pm of the
facility's interior revealed:

-Client #3's bedroom did not have a bedroom
door.

Interview on 8/13/25 with Client #3 revealed:
-Did not have a bedroom door.

-Didn't notice every other bedroom had a door
"..doors can't be closed anyways."

|
| Interview on 8/13/25 with Staff #1 revealed:
-"Never been a door on that room (Client #3's
| bedroom), | don't know why."

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

STATE FORM 6899 XLKT11 If continuation sheet 1 of 2

PRINTED: 08/21/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. BUILDING: COMPLETED
R
MHL014-006 B. WING ____ 08/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD

BURKWELL
LENOIR, NC 28645
(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 4 v736— |

-Never asked why there wasn't a door.

|
Interview on 8/12/25 with the House Manager

revealed

-Client #3's bedroom hadn't had a door since

| "y'all (Division of Health and Service Regulation)

| came out last time (9/10/24)."

| -...trying to find a door to fit the frame, can't find

one."

-The Director was responsible for finding a door

| for Client #3's bedroom.

Interviews on 8/12/25 and 8/13/25 with the |
| Qualified Professional #1 revealed:

-"Never noticed (Client #3 did not have a
bedroom door) because clients have to be in

| eyesight of staff at all times."

| -"[Client #3] didn't say anything about not having
a door." | |
-"Never thought anything about the door. Didn't
ask anybody about it.”

Interview on 8/13/25 with the Licensed
Professional revealed:

-Not sure why he (Client #3) doesn't have a door
(bedroom door).”

Interview on 8/13/25 with the Director revealed: |
-| dropped the ball on that (putting a door on
Client #3's bedroom)."

-"I didn't call back (to the contractor) to have the
door put on.”

-"Clients don't close their doors ever, but |
understand a door still needs to be put on for
safety, in case of a fire."

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

Division of Health Service Regulation
STATE FORM Said XLKT11 if continuation sheet 2 of 2

PRINTED: 08/21/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R

MHL014-006 B. WING __ 08/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

(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)

BURKWELL

V 000] INITIAL COMMENTS Vv 000

An annual and follow up survey-was completed
on August 14, 2025. A deficiéncy was 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 8 and currently has a
census of 8. The survey sample consisted of
audits of 3 current clients.

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

410A 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 manner. The
findings are:

Observation on 8/12/25 at 12:50pm of the
facility's interior revealed:

-Client #3's bedroom did not have a bedroom
door.

Interview on 8/13/25 with Client #3 revealed:
-Did not have a bedroom door.

-Didn't notice every other bedroom had a door
"| doors can't be closed anyways."

Interview on 8/13/25 with Staff #1 revealed:
-"Never been a door on that room (Client #3's
| bedroom), | don't know why."

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE

STATE FORM 6899 XLKT11 if continuation sheet 1 of 2

STATE FORM: REVISIT REPORT

PROVIDER / SUPPLIER / CLIA/. [MULTIPLE CONSTRUCTION DATE OF REVISIT
IDENTIFICATION NUMBER A. Building
MHLO14-006 v1 [B. Wing yo (8/14/2025 yg

STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

NAME OF FACILITY
BURKWELL

This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such
corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the
identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey
report form).

ITEM DATE ITEM DATE
y4 Y5 Y4 Y5
ID Prefix vo118 Correction | ID Prefix v0119 Correction | ID Prefix vo123 Correction
27G .0209 (C. 27G .0209 (D) 27G .0209 (H)

Reg. # - (¢) Completed | Reg. # ©) Completed }| Reg. # a ) Completed
Lsc 08/14/2025 Lsc 08/14/2025 LSC 08/14/2025
ID Prefix Correction | ID Prefix Correction | ID Prefix Correction
Reg. # Completed | Reg. # Completed | Reg. # : Completed
Lsc Lsc LSC

ID Prefix Correction | ID Prefix Correction | !D Prefix Correction
Reg. # Completed | Reg. # Completed | Reg. # _ Completed
LSC ee LSC _ Lsc

ID Prefix Correction | ID Prefix Correction | ID Prefix Correction
Reg. # Completed | Reg. # Completed | Reg. # Completed
LSc - LSC LSc . ee

ID Prefix Correction ID Prefix Correction ID Prefix Correction
Reg. # Completed | Reg. # Completed | Reg. # Completed
Lsc oe LSC a Lsc _

REVIEWED BY REVIEWED BY SIGNATURE OF SURVEYOR DATE

STATE AGENCY INITIALS) p

Co] anmacs) Ly Arey WloPallle 8/14/25
REVIEWED BY REVIEWED BY DATE TITLE DATE
CMS RO (| (INITIALS)

([ CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF

FOLLOWUP TO SURVEY COMPLETED ON
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? (yes [[] NO

9/10/2024

Page 1 of 1 EVENT ID: ERLI12
STATE FORM: REVISIT REPORT (11/06)

inspection_type: MHLCS Annual and Follow-up


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

raw_content:
PRINTED: 08/21/2025
FORM APPROVED
Division of Health Service Regulation

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

R
MHL014-006 B. WING _____ 08/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
LENOIR, NC 28645

(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)

BURKWELL

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on August 14, 2025. A deficiency was 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 8 and currently has a
census of 8. 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 observation and interview, the facility
was not maintained in a safe manner. The
indings are:

Observation on 8/12/25 at 12:50pm of the
acility's interior revealed:

-Client #3's bedroom did not have a bedroom
door.

nterview on 8/13/25 with Client #3 revealed:
-Did not have a bedroom door.

-Didn't notice every other bedroom had a door
"...doors can't be closed anyways."

nterview on 8/13/25 with Staff #1 revealed:
-"Never been a door on that room (Client #3's
bedroom), | don't know why."

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

STATE FORM 6899 XLKT11 If continuation sheet 1 of 2

PRINTED: 08/21/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL014-006 B. WING 08/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3476 MORGANTON BOULEVARD
BURKWELL
LENOIR, NC 28645
(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

-Never asked why there wasn't a door.

Interview on 8/12/25 with the House Manager
revealed:

-Client #3's bedroom hadn't had a door since
"y'all (Division of Health and Service Regulation)
came out last time (9/10/24)."

-"...trying to find a door to fit the frame, can't find
one."

-The Director was responsible for finding a door
for Client #3's bedroom.

Interviews on 8/12/25 and 8/13/25 with the
Qualified Professional #1 revealed:

-"Never noticed (Client #3 did not have a
bedroom door) because clients have to be in
eyesight of staff at all times."

-"[Client #3] didn't say anything about not having
a door."

-"Never thought anything about the door. Didn't
ask anybody about it."

Interview on 8/13/25 with the Licensed
Professional revealed:

-"Not sure why he (Client #3) doesn't have a door
(bedroom door)."

Interview on 8/13/25 with the Director revealed:
-"| dropped the ball on that (putting a door on
Client #3's bedroom)."

-"| didn't call back (to the contractor) to have the
door put on."

-"Clients don't close their doors ever, but |
understand a door still needs to be put on for
safety, in case of a fire."

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

Division of Health Service Regulation
STATE FORM 6899 XLKT11 If continuation sheet 2 of 2