facility_name: A Mother's Love

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

raw_content:
Division

of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHLOO1-281

A, BUILDING: —________

PRINTED: 02/13/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

(x4) ID
PREFIX
TAG

v 000

BURLINGTON, NC 27217

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

INITIAL COMMENTS

An annual and follow up survey was completed
on February 10, 2026. Deficiencies were cited.
This facility is licensed for the following service

category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

This facility is licensed for 4 and has a current

census of 4. The survey sample consisted of
audits of 3 current clients.

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

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

PLAN

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

(6)written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

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

X.

STATE FORM

6899)

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

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

DEFICIENCY)

TITLE

QP

(X6) DATE

February 20, 2026

6BX911

If continuation sheet, of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B.WING

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

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
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

(x5)
COMPLETE
DATE

V112 Continued From page 1

This Rule is not met as evidenced by:

Based on record reviews, and interviews, the
facility failed to develop and implement treatment
goals and strategies to address the needs of one
of three audited clients (Client #3). The findings
are:

Review on 2/10/26 of Client #3's record revealed:
-Admission date of 7/15/24.

-Diagnoses of Disinhibited Social Engagement
Disorder; Attention Deficit Hyperactivity Disorder,
Combined Type; Circadian Rhythm Sleep Wake
Disorder; Intellectual Disability.

-She was 16 years old.

-The treatment plan had no strategies to address
elopement or the stealing of food from the
refrigerator.

Review on 2/10/26 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-Incident reports indicating that Client #3 eloped
from the facility on the following dates: 8/29/25,
11/29/25, 12/7/25, 12/26/25, 1/19/26, 2/5/26.
Interview on 2/10/26 with Client #3 revealed:
-She liked the facility, staff and other clients.
-Admitted walking away from the facility when
upset.

-Did not walk too far from the facility and stayed
within the same neighborhood.

Interview on 2/10/26 with the Director revealed:

Division of HealthServiceRegulation

STATE FORM 6899

v112

Corrective Action Taken:

The consumer's Person-Centered Plan (PCP)
was reviewed and revised to address the
deficient area of practice. Two additional
treatment goals were developed to specifically
target the behaviors of elopement and stealing
food from the refrigerator/cabinets. These
goals include measurable strategies and staff
interventions designed to reduce the
frequency of these behaviors and increase
appropriate coping and decision-making skills.
The updated PCP was reviewed with the
consumer and her treatment team on Monday,
February 16, 2026. All required signatures for
the revised PCP were obtained by Tuesday,
February 17, 2026.

02/17/2026

Measures to Prevent Recurrence:

The facility has implemented a procedure
requiring treatment plans to be reviewed for
behavioral trends identified through incident
reports and staff observations. Any emerging
or recurring behaviors will be addressed
through timely treatment plan updates to
ensure goals and strategies align with the
consumer's current needs.

Staff will receive guidance on promptly
reporting behavioral patterns to the Qualified
Professional (QP) so that treatment planning
adjustments occur without delay.

Monitoring Plan:

The Qualified Professional (QP) will be
responsible for monitoring the implementation
and effectiveness of the new goals addressing
elopement and stealing behaviors.

Frequency of Monitoring:

The PCP will be reviewed monthly to assess
progress toward the new goals. Progress and
ongoing needs will also be discussed during
the consumer’s monthly Child and Family
Team (CFT) meetings. Incident reports related
to elopement and stealing will be reviewed as
they occur to determine if additional
interventions are needed.

6BX911 If continuation shee® of 14

PRINTED: 02/13/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION. (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLOO1-281 B.WING 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(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 OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

A MOTHER'S LOVE

V112 Continued From page 2 v1412

-She acknowledged Client #3's plan did not have
strategies to address eloping and the stealing of
food from refrigerator/cabinet.

-Treatment Team was scheduled to meet
upcoming Friday to discuss her recent behaviors
which included eloping and the stealing of food.
-Treatment plan was to be updated.

-She acknowledged that although Client #3's plan
mentioned her stealing, it did not have strategies
set in place to address said behavior.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION

REQ UIREM ENT S

(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
drug.

Division of Health Service Regulation
STATE FORM 6899 6BX911 If continuation sheeB of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B.WING

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

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
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

(x5)
COMPLETE
DATE

V118 Continued From page 3

(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 review and interview, the facility
failed to have physician's orders current affecting
one of three clients (Client #3). The findings are:
Review on 2/10/26 of Client #3's record revealed:
-Admission date of 7/15/24.

-Diagnoses of Disinhibited Social Engagement
Disorder; Attention Deficit Hyperactivity Disorder,
Combined Type; Circadian Rhythm Sleep Wake
Disorder; Intellectual Disability.

-There were no current physician's orders for the
following medications:

-Hydrocortisone 5 milligrams (mg) (skin)-
Take two tablets daily in the morning. Last order
written on 10/2/24.

-Hydrocortisone 5 mg- Take one tablet daily
in the afternoon. Last order written on 10/2/24.

-Hydrocortisone 5 mg- Take one tablet daily
in the evening at bedtime. Last order written on
10/2/24.

-Simvastatin 10 mg (cholesterol)- Take one
tablet daily in the evening at bedtime. Last order
written on 1/16/25.

Observation on 2/10/26 of Client #3's medications
revealed:
-All medications mentioned were available.

Division of Health Service Regulation

STATE FORM 6899

Vv118

Corrective Action Taken:

The pharmacy was immediately contacted,
and updated physician’s orders were
obtained for Client #3’s Hydrocortisone and
Simvastatin. All expired prescriptions were
replaced with current physician orders. At
this time, all medications and prescriptions
for Client #3 are current and valid, and the
facility is receiving medications as
prescribed.

02/20/2026

Measures to Prevent Recurrence:

The facility has implemented a procedure to
ensure that all medication orders remain
current. All medications are maintained on a
four-week cycle through the pharmacy,
which requires valid physician orders for
continued dispensing. Staff will verify
prescription expiration dates during routine
medication checks to ensure no
medications are administered without a
current physician’s order.

In addition, medication records will be
reviewed during the pharmacy’s scheduled
six-month Medication Administration Record
(MAR) audit to identify and correct any
expired or expiring prescriptions.

Monitoring Plan:

The Qualified Professional (QP) will be
responsible for monitoring medication
records to ensure that all physician orders
remain current.

Frequency of Monitoring:

Medication orders will be reviewed during
each six-month MAR audit conducted by
the pharmacy and as part of ongoing record
reviews by the QP. Any expired or expiring
orders identified will be addressed
immediately by obtaining updated physician
orders.

6BX911 If continuation sheet of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHLOO1-281 B.WING _____

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27217

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
1227 WESTMORELAND DRIVE

CROSS-REFERENCED TO THE APPROPRIATE

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

DEFICIENCY)

V 118 Continued From page 4

Review on 2/10/26 of Client #3's MARs for
December 2025 through February 10, 2026
revealed:

-All medications mentioned had been marked as
administered.

Interview on 2/10/26 with the Director revealed:

-She was not aware that the scripts for Client #3's
medications had expired.

-She was going to get new orders from Client

#3's physician.

-She acknowledged the medication orders for
Client #3's Hydrocortisone and Simvastatin had
expired.

This deficiency constitutes a re-cited deficiency

and must be corrected within 30 days.

G.S. 122C- 62 Additional Rights in 24 Hour
F ac ilities
§ 122C-62. Additional Rights in 24-Hour

F ac ilities .

(a)In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-61, each adult client
who is receiving treatment or habilitation in a
24-hour facility keeps the right to:

(1)Send and receive sealed mail and have

access to writing material, postage, and staff
assistance when necessary;

(2)Contact and consult with, at his own expense
and at no cost to the facility, legal counsel, private
physicians, and private mental health,
developmental disabilities, or substance abuse
professionals of his choice; and

(3)Contact and consult with a client advocate if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each adult client may

Division of Health Service Regulation

STATE FORM 6899

6BX911

If continuation shee6 of 14

Division of Health Service Regulation

PRINTED: 02/13/2026

FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A, BUILDING: —________

B.WING

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

(x4) ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

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

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

(x5)
COMPLETE
DATE

V 364 Continued From page 5

exercise these rights at all reasonable times.
(b)Except as provided in subsections (e) and (h)
of this section, each adult client who is receiving
treatment or habilitation in a 24-hour facility at all
times keeps the right to:
(1)Make and receive confidential telephone
calls. All long distance calls shall be paid for by
the client at the time of making the call or made
collect to the receiving party;
(2)Receive visitors between the hours of 8:00
a.m. and 9:00 p.m. for a period of at least six
hours daily, two hours of which shall be after 6:00
p.m.; however visiting shall not take precedence
over therapies;
(3)Communicate and meet under appropriate
supervision with individuals of his own choice
upon the consent of the individuals;
(4)Make visits outside the custody
unless:

the facility

a. Commitment proceedings were initiated as
the result of the client's being charged with a
violent crime, including a crime involving an
assault with a deadly weapon, and the
respondent was found not guilty by reason of
insanity or incapable of proceeding;

Bhe client was voluntarily admitted or

committed to the facility while under order of
commitment to a correctional facility of the
Division of Adult Correction of the Department of
Public Safety; or

c. Theclient is being held to determine capacity
to proceed pursuant to G.S. 15A-1002;

A court order may expressly authorize visits
otherwise prohibited by the existence of the
conditions prescribed by this subdivision;

(5)Be out of doors daily and have access to
facilities and equipment for physical exercise
several times a week;

(6)Except as prohibited by law, keep and use

Division of Health Service Regulation
STATE FORM

6899

V364

Corrective Action Taken:

The facility immediately unlocked all locking devices from
the refrigerator and freezer. Clients’ access to food is no
longer restricted. The snack cabinet is no longer used to
restrict client access to food. All personal snacks have
been moved into individual labeled containers for each
client.

Clients now have access to their personal snacks upon
request, and staff provide assistance to ensure snacks are
distributed appropriately and safely. The facility continues
to prepare meals daily in sufficient quantities to meet the
nutritional needs of ail clients based on recommended
portion sizes.

02/20/2026

Clients are permitted to prepare their own breakfast and
lunch when appropriate, primarily on weekends and when
school is not in session, under staff supervision.

Measures to Prevent Recurrence:

The facility has implemented a procedure prohibiting the
use of locks or physical barriers to restrict client access to
food unless such restriction is clinically justified,
documented in the client's treatment plan, and approved by
the Human Rights Committee.

Any future concerns related to food-related behaviors will
be addressed through individualized treatment planning,
behavior support strategies, and staff supervision rather
than environmental restriction.

Treatment plans will be updated to include specific goals
and strategies when food-related behaviors are identified.
Staff have been instructed that client rights may not be
restricted without proper documentation, evaluation, and
Human Rights Committee approval.

Monitoring Plan:

The Qualified Professional (QP) will be responsible for
monitoring food access practices and treatment plan
documentation to ensure compliance with client rights
requirements.

Frequency of Monitoring:

The QP will review food access practices weekly and will
review treatment plans monthly to ensure that no
unauthorized restrictions are in place. Any concerns will be
addressed immediately.

6BX911 If continuation sheet of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHLOO1-281 B.WING _____

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27217

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
1227 WESTMORELAND DRIVE

CROSS-REFERENCED TO THE APPROPRIATE

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

DEFICIENCY)

V 364 Continued From page 6

personal clothing and possessions, unless the
client is being held to determine capacity to
proceed pursuant to G.S. 15A-1002;
(7)Participate in religious worship;

(8)Keep and spend a reasonable sum of his

own money;

(9)Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes;
and

(10)Have access to individual storage space for
his private use.

(c)In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-57 and GS.

122C-59 through G.S. 122C-61, each minor client
who is receiving treatment or habilitation in a
24-hour facility has the right to have access to
proper adult supervision and guidance. In
recognition of the minor's status as a developing
individual, the minor shall be provided
opportunities to enable him to mature physically,
emotionally, intellectually, socially, and
vocationally. In view of the physical, emotional,
and intellectual immaturity of the minor, the
24-hour facility shall provide appropriate
structure, supervision and control consistent with
the rights given to the minor pursuant to this Part.
The facility shall also, where practical, make
reasonable efforts to ensure that each minor
client receives treatment apart and separate from
adult clients unless the treatment needs of the
minor client dictate otherwise.

Each minor client who is receiving treatment or
habilitation from a 24-hour facility has the right to:
(1)Communicate and consult with his parents or
guardian or the agency or individual having legal
custody of him;

(2)Contact and consult with, at his own expense
or that of his legally responsible person and at no
cost to the facility, legal counsel, private

Division of Health Service Regulation

STATE FORM 6899

6BX911

If continuation sheet of 14

PRINTED: 02/13/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION. (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLOO1-281 B.WING 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(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 OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

A MOTHER'S LOVE

V 364 Continued From page 7 V 364

physicians, private mental health, developmental
disabilities, or substance abuse professionals, of
his or his legally responsible person's choice; and
(3)Contact and consult with a client advocate, if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each minor client
may exercise these rights at all reasonable times.
(d)Except as provided in subsections (e) and (h)
of this section, each minor client who is receiving
treatment or habilitation in a 24-hour facility has
the right to:

(1)Make and receive telephone calls. All long
distance calls shall be paid for by the client at the
time of making the call or made collect to the
receiving party;
(2)Send and receive mail and have access to
writing materials, postage, and staff assistance
when necessary;
(3)Under appropriate supervision, receive
visitors between the hours of 8:00 a.m. and 9:00
p.m. for a period of at least six hours daily, two
hours of which shall be after 6:00 p.m.; however
visiting shall not take precedence over school or
therapies;
(4)Receive special education and vocational
training in accordance with federal and State law;
(5)Be out of doors daily and participate in play,
recreation, and physical exercise on a regular
basis in accordance with his needs;

(6)Except as prohibited by law, keep and use
personal clothing and possessions under
appropriate supervision, unless the client is being
held to determine capacity to proceed pursuant to
G.S. 15A-1002;

(7)Participate in religious worship;

(8)Have access to individual storage space for

the safekeeping of personal belongings;

(9)Have access to and spend a reasonable sum

Division of Health Service Regulation
STATE FORM 6899 6BX911 If continuation shee® of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

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

MHLOO1-281 B.WING _____

(X2) MULTIPLE CONSTRUCTION
A, BUILDING: —________

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZI
1227 WESTMORELAND DR
BURLINGTON, NC 27217

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

A MOTHER'S LOVE

(x4) ID
PREFIX
TAG

P CODE
IVE

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

(x5)
COMPLETE
DATE

V 364 Continued From page 8

of his own money; and
(10)Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes.
(e)No right enumerated in subsections (b) or (d)

of this section may be limited or restricted except
by the qualified professional responsible for the
formulation of the client's treatment or habilitation
plan. A written statement shall be placed in the
client's record that indicates the detailed reason
for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective fora
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional at least every seven days,

at which time the restriction may be removed.
Each evaluation of a restriction shall be
documented in the client's record. Restrictions on
rights may be renewed only by a written

statement entered by the qualified professional in
the client's record that states the reason for the
renewal of the restriction. In the case of an adult
client who has not been adjudicated incompetent,
in each instance of an initial restriction or renewal
of a restriction of rights, an individual designated
by the client shall, upon the consent of the client,
be notified of the restriction and of the reason for
it. In the case of a minor client or an incompetent
adult client, the legally responsible person shall

be notified of each instance of an initial restriction
or renewal of a restriction of rights and of the
reason for it. Notification of the designated
individual or legally responsible person shall be
documented in writing in the client's record.

Division of Health Service Regulation

STATE FORM 6899

6BX911

If continuation shee® of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

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

(X2) MULTIPLE CONS

MHLOO1-281 B.WING _____

A, BUILDING: —________

STRUCTION (X3) DATE SURVEY

COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZI
1227 WESTMORELAND DR

BURLINGTON, NC 27217

A MOTHER'S LOVE

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

(x4) ID
PREFIX
TAG

P CODE
IVE

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

(x5)
COMPLETE
DATE

V 364 Continued From page 9

This Rule is not met as evidenced by:

Based on observation, record reviews and
interviews, the facility restricted the rights of three
of three audited clients (#1, #2 and #3) by
restricting their access to food. The findings are:

Observation on 2/10/26 at 2:45 pm of the facility's
kitchen eyealed ad three locking cables
attached to its door. A key was needed to open
the refrigerator. Cables were unlocked at the time
of observation.

-Cabinets- One of the cabinets was labeled
"Snacks" and had a lock attached to the door.
Cabinet door was locked.

Review on 2/10/26 of Client #1's record revealed:

-Admission date of 11/14/24.

-Diagnoses of Major Depressive Disorder,
Recurrent, Moderate; Oppositional Defiant
Disorder; Unspecified Trauma and Stressor
Related Disorder; Post Traumatic Stress
Disorder; Disruptive Mood Dysregulation
Disorder; High Risk Sexual Behavior; Child
Sexual Abuse, Suspected, Subsequent
Encounter.
-There was no documentation of detailed reason
for the restriction and no evaluation of the
restriction.
-No documentation of approval from the Human
Rights Committee for restriction of clients
accessing the refrigerator or snack cabinet.

Review on 2/10/26 of Client #2's record revealed:

-Admission date of 9/21/25.

-Diagnoses of Adjustment Disorder with Mixed
Disturbance & Conduct; Trauma Related Stress
Disorder; Generalized Anxiety Disorder; Child in
DSS Custody.

Division of HealthServiceRegulation

STATE FORM 6899

6BX911

If continuation sheetl0 of 14

PRINTED: 02/13/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION. (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLOO1-281 B.WING 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217
(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 OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

A MOTHER'S LOVE

V 364 Continued From page 10 -There was no V364

documentation of detailed reason

for the restriction and no evaluation of the
restriction.

-No documentation of approval from the Human
Rights Committee for restriction of client
accessing the refrigerator.

Review on 2/10/26 of Client #3's record revealed:

-Admission dated of 7/15/24.

-Diagnoses of Disinhibited Social Engagement
Disorder; Attention Deficit Hyperactivity Disorder,
Combined Type; Circadian Rhythm Sleep Wake
Disorder; Intellectual Disability.

-Treatment plan dated 1/21/26 did not include
documentation of food related behaviors.
-There was no documentation of detailed reason
for the restriction and no evaluation of the
restriction.

-No documentation of approval from the Human
Rights Committee for restriction of client
accessing the refrigerator.

Interview on 2/10/26 with Client #1 revealed:

-She had seen the refrigerator locked.

-She had heard that Client #3 had been taking
people's food from the refrigerator.

-Facility normally always gave them their meals.

Interview on 2/10/26 with Client #2 revealed:

-Facility always gave them their meals.

-Facility mostly made enough meal for the day
and did not refrigerate left overs.

-She had seen the refrigerator being locked.

-If she wanted one of her snacks, she would ask
staff to grab it.

Interview on 2/10/26 with Client #3 revealed:

-She had seen the refrigerator being locked.
-Facility gave clients their meals. Clients did not
prepare meals.

Division of HealthServiceRegulation
STATE FORM 6899 6BX911 If continuation sheetL1of 14

PRINTED: 02/13/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION. (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLOO1-281 B.WING 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(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 OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

A MOTHER'S LOVE

V 364 Continued From page 11 -She did not know why the V 364

refrigerator was being
locked.

-Staff locked their snacks in the kitchen.

Interview on 2/10/26 with the Director revealed:

-She was not aware that the refrigerator could not
be locked.

-Facility staff had placed the locking cables to
curb Client #3's behavior of stealing other client's
foods.

-Client's snacks were also locked to prevent
clients from eating other client's snacks.

-"If clients ever needed anything, like water and
snacks, staff would just assist the client and give
them what they needed."

-When the clients were in school, the facility
provided breakfast, two snacks and dinner for the
day.

Interview on 2/10/26 with the Owner revealed:

-She was planning on appealing deficiency cited.
-Facility had to place the lock cables on the
refrigerator because Client #3 was taking the
other client's food and rubbing it on her private
areas and placing it back in.

-She did not know other ways to curb said
behavior.

-She had not contacted disability rights committee
to receive approval to lock the refrigerator or
snack cabinet.

-Clients at the facility were never allowed to use
the refrigerator or to have direct access to foods
as they tried to prevent food being contaminated
by the client's hands.

-Clients were not allowed to fix meals.

-She acknowledged there was no documentation
placed on each of the client's treatment plans
indicating the restriction to the refrigerator or
snack cabinet.

Division of Health Service Regulation
STATE FORM 6899 6BX911 If continuation sheetL2 of 14

Division of Health Service Regulation

PRINTED: 02/13/2026
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A, BUILDING: —________

B.WING

(X3) DATE SURVEY
COMPLETED

R
02/10/2026

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

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

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

V 736 Continued From page 12

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

10A NCAC 27G .0303 LOCATION AND V 736

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
and its grounds were not maintained in a clean,
attractive, and orderly manner. The findings are:

Observation on 2/10/26 of the faciity at about 2:45
pm revealed:

-Hall bathroom- Vanity lamp had two burnt
ight bulbs.

-Client #3's bedroom- The outside bottom
pane glass for the left window was
cracked/broken. Tape was on top of the cracked
glass.
-Back Deck- The wood was weathered. Paint
had been worn off from about a quarter of the
deck exposing the wood to the elements.

Interview on 2/10/26 with the Director revealed:

-Acknowledged the window in Client #3's
bedroom was cracked. An order was placed, but
it was taking long to repair.

-She was not aware the light bulbs in the
bathroom had burnt.

-Acknowledged wood on back deck was
weathered and in need of repainting.

Interview on 2/10/26 with the Owner revealed:

-She had placed an order to repair the window in
Client #3's bedroom, but things were now taking
longer to fix than before. She would follow up to

Division of Health Service Regulation
STATE FORM 6899

V736

Corrective Action Taken:

The facility immediately replaced the burnt-
out light bulbs in the hall bathroom vanity
fixture.

The facility has scheduled repairs for the
cracked window in Client #3’s bedroom.
The window will be replaced within the
required 60-day correction period.

The facility has also scheduled repainting
of the back deck. The deck will be
repainted within the required 60-day
correction period to protect the wood from
further weathering and deterioration.

04/11/2026

Measures to Prevent Recurrence:

The facility has implemented a routine
environmental inspection process to
identify maintenance concerns such as
lighting, windows, and exterior structures.
Maintenance needs will be reported
promptly and addressed in a timely manner
to ensure the facility remains clean,
attractive, and orderly.

Staff have been instructed to report
maintenance concerns immediately to
administration so that repairs can be
initiated without delay.

Monitoring Plan:

The Director and QP will be responsible for
monitoring the condition of the facility and
ensuring that maintenance issues are
corrected.

Frequency of Monitoring:

The facility will be inspected weekly by the
Director or designee to identify and address
maintenance concerns. All identified issues
will be tracked until resolved.

6BX911 If continuation sheetL3 of 14

PRINTED: 02/13/2026
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLOO1-281 B.WING 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

A MOTHER'S LOVE
BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE Oe tE S

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

V 736 Continued From page 13

have it repaired soon.

Division of Health Service Regulation
STATE FORM 6899 6BX911 If continuation sheetL4 of 14

inspection_type: MHLCS Annual and Follow-up


state: NC

raw_content:
PRINTED: 03/03/2025
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

MHLOO1-281 . 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

A MOTHER'S LOVE

V000 INITIAL COMMENTS

An annual and follow up survey was completed
on 2/26/25. Deficiencies were cited.
This facility is licensed for the following service

category: LOA NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

This facility is licensed for 4 and has a current

census of 4. The survey sample consisted of
audits of 3 current clients. Onboarding paperwork
will begin within 48 hours

of offer acceptance.
Corrective p

27G .0202 (A-E) Personnel Requirements Measures

Employee's file will be
updated to be in
compliance.

OA NCAC 27G .0202 PERSONNEL

REQ UIREM ENT S
(a) All facilities shall have a written job
description for the director and each staff position
which: All educational
(specifies the minimum level of education, mavente documents will be
competency, work experience and other obtained before hire date.
ualifications for the position;
(2) specifies the duties and responsibilities of
he position;
(3)is signed by the staff member and the Who will
supervisor; and Monitor
(4)is retained in the staff member's file.
(b) All facilities shall ensure that the director,
each staff member or any other person who z
. . To ensure compliance,
pefealige or services to clients on behalf of Owner will review the
: How Often personnel record of
(1) is at least 18 years of age; incoming staff prior to hire
(2)is able to read, write, understand and date.
follow directions;
(3)meets the minimum level of education,
competency, work experience, skills and other
qualifications for the position; and
(4) has no substantiated findings of abuse or
neglect listed on the North Carolina Health Care
Personnel Registry.
Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
VAN izzy Brown Owner, QP March 13, 2025
STATE FORM 6899) QDRS11. Tf continuation sheet 1 of 19
Received by

3/14/25

PRINTED: 03/03/2025

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
MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
AMOTHER'S LOVE 1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

(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 107 Continued From page 1 (c) All facilities or services V 107

shall require that all

applicants for employment disclose any criminal
conviction. The impact of this information ona
decision regarding employment shall be based
upon the offense in relationship to the job for
which the applicant is applying.

(d) Staff of a facility or a service shall be
currently licensed, registered or certified in
accordance with applicable state laws for the
services provided.

(e) A file shall be maintained for each individual
employed indicating the training, experience and
other qualifications for the position, including
verification of licensure, registration or
certification.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to have a complete personnel record
affecting one of one audited paraprofessional
staff (#1). The findings are:

Review on 2/26/25 of the personnel record for
staff #1 revealed:

-No specific date of hire.

-No documentation of educational verification.
Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-Staff #1 had been with her facility for a "little"
over a year.

-"We just had an accreditation review and all of

Division of Health Service Regulation

STATE FORM 6899 QDRS11 If continuation sheet 2 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V 107 Continued From page 2

the documentation was available for [staff #1]."
-She was unable to locate a copy of staff #1's
high school diploma.

-"I'm just going to have to take the hit for that
one."
-She confirmed the facility failed to have a
complete personnel record for staff #1.

27G .0209 (C) Medication Requirements

0A NCAC 27G .0209 MEDICATION
REQ UIREM ENT S

(c) Medication administration:
) Prescription or non-prescription drugs shall
nly be administered to a client on the written
rder of a person authorized by law to prescribe
rugs.

2) Medications shall be self-administered by
ients only when authorized in writing by the
ient's physician.

3) Medications, including injections, shall be
dministered only by licensed persons, or by
nlicensed persons trained by a registered nurse,
harmacist or other legally qualified person and
rivileged to prepare and administer medications.
4) A Medication Administration Record (MAR) of
(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
drug.
(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation

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»

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 3 of 19

Division of Health Service Regulation

PRINTED: 03/03/2025
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

02/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

A MOTHER'S LOVE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

DEFICIENCY)

(x5)
COMPLETE
DATE

V118 Continued From page 3

with a physician.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to keep the MAR current affecting
one of three clients (#1). The findings are:
Observation on 2/26/25 at approximately 1:27 pm
of client #1's medication bin revealed:

-There was no Vitamin D3 50 micrograms (mcg)
(Bone health), Atorvastatin 20 milligrams (mg)
(High Cholesterol), Co-Enzyme Q10 200 mg
(Energy) and Omeprazole 20 mg (Heartburn)
available for client #1.

Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

-Physician's orders dated 11/13/24 for the
following medications:

Vitamin D3 50 mcg, one tablet daily
Atorvastatin 20 mg, one tablet daily
Co-Enzyme Q10 200 mg, one capsule daily
Omeprazole 20 mg, one capsule daily

Review on 2/26/25 of MARs for client #1
revealed:

No staff initials to indicate the medication was
administered for the following:

Division of Health Service Regulation
STATE FORM 6899

QDRS11

All staff will receive
supervision training on MAR
documentation to correct the
deficient area. Training will
include the need for accuracy
and timeliness.Staff will
receive written documentation
from prescribing physician for
any discontinuance of
medicines.

Corrective
Measures

The MARs will be signed daily
by staff administering the
medication.Program Manager
will be asked to check for any
unmarked areas or errors on
the MAR daily. Should an error
be identified, the error will be
corrected before staff leaves
the shift. If necessary,
supervisor will be contacted
and medication errors will be
documented as a Level I
incident.

Preventive
Measures

Who will
Monitor

Owner, Program Manager,
Pharmacy

All MARs will be audited for
completion and accuracy ona
weekly basis by Owner or
Program Manager.All MARs will
be audited by the distributing
pharmacy bi-annually

How Often

If continuation sheet 4 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V118 Continued From page 4

February 2025-

-Vitamin D3 50 mcg on 2/1 thru 2/26
-Atorvastatin 20 mg on 2/7 thru 2/26
-Co-Enzyme Q10 200 mg on 2/7 thru 2/26
-Omeprazole 20 mg on 2/7 thru 2/26

-No documentation to indicate the medication
was not available for administration

January 2025-

-Vitamin D3 50 mcg on 1/1 thru 1/31
-No documentation to indicate the medication
was not available for administration

Interview on 2/26/25 with client #1 revealed:

-Some of her medications were not available
because she had to see the doctor to get refills.
-She had blood work completed about a week
ago in order to get one of those medications
refilled.

-She had not taken some of those medications
for most of the month (February 2025).

-She wasn't sure when she would be seeing the
doctor in order to have those medications refilled.

Interview on 2/26/25 with the Program Manager

revealed:

-Client #1's February and January 2025 MARs
had no staff initials for some of the medications
because she ran out of those medications.

-Some of client #1's medications were not
available because they were waiting on the doctor
to write an order to have those medications
refilled.

-Client #1 required lab work for one of those
medications, which they just recently had done
this month (February 2025).

-She (Program Manager) called the medical

office several times and tried to speak with the
doctor and/or schedule an appointment to get the
medication refilled.

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 5 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V118 Continued From page 5

-She was told the doctor was busy or seeing
another patient.

-Staff did not indicate the medication was not
available on the February and January 2025
MARSs for client #1.

-She confirmed the MARs were not current client
#1.

Interview on 2/26/25 with the Director/Qualified

Professional revealed:

-She wasn't aware of some of client #1's
medications not being available.

-"I know medical appointments for clients can be
difficult to make."

-"It all boils down to Medicaid, they have to find
doctors that accept Medicaid."

-She confirmed the MARs were not current client
#1.

G.S. 131E-256 (D2) HCPR - Prior Employment Vv 131
Verification

G.S. §131E-256 HEALTH CARE PERSONNEL

REG IST RY

(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure the Health Care Personnel

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 6 of 19

Division of Health Service Regulation

PRINTED: 03/03/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

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

MHLOO1-281

(X3) DATE SURVEY
COMPLETED

02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

A MOTHER'S LOVE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

(x5)
COMPLETE

DEFICIENCY)

V131 Continued From page 6

Registry (HCPR) was accessed prior to
employment affecting one of one audited
paraprofessional staff (#1). The findings are:

Review on 2/26/25 of the personnel record for

staff #1 revealed:

-No specific date of hire.

-No documentation the HCPR was accessed
prior to hire.

Interview on 2/26/25 with the Director/Qualified

Professional revealed:

-Staff #1 had been with her facility for a little over
a year.

-"We just had an accreditation review and all of
the documentation was available for [staff #1]."
-She recalled doing the HCPR check for staff #1.
-She was not sure why the HCPR check was not
in staff #1's personnel record.

-She confirmed the facility failed to ensure the
HCPR was accessed for staff #1 prior to
employment.

Preventive
Measures

How Often

27G .1301 Residential Tx - Scope

110A NCAC 27G .1301 SCOPE

(a) The rules of this Section apply only toa
residential treatment facility that provides
residential treatment, level II, program type
service.

(b) A residential treatment facility providing
residential treatment, level III service, shall be
licensed as set forth in 10A NCAC 27G .1700.

(c) A residential treatment facility for children and
adolescents is a free-standing residential facility
which provides a structured living environment
within a system of care approach for children or
adolescents who have a primary diagnosis of
mental illness or emotional disturbance and who

Division of Health Service Regulation

STATE FORM 6899 QDRS11

Corrective Measures

Who will Monitor

Onboarding paperwork will begin
within 48 hours of offer
acceptance.

Employee's file will be updated
to be in compliance.

The results of HCPR will be
obtained before hire date.

To ensure compliance, Owner
will review the personnel record
of incoming staff prior to hire
date.

If continuation sheet 7 of 19

Division of Health Service Regulation

PRINTED: 03/03/2025
FORM APPROVED

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

(X2) MULTIPLE CONSTRUCTION

MHLOO1-281 B.WING__

A, BUILDING: —_________

(X3) DATE SURVEY
COMPLETED

------ 02/26/2025

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

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

A MOTHER'S LOVE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

V179 Continued From page 7

may also have other disabilities.

(d) Services shall be designed to address the
functioning level of the child or adolescent and
include training in self-control, communication
skills, social skills, and recreational skills.
Children or adolescents may receive services in a
day treatment facility, have a job placement, or
attend school.

(e) Services shall be designed to support the
child or adolescent in gaining the skills necessary
to return to the natural, or therapeutic home
setting.

(f) The residential treatment facility shall
coordinate with other individuals and agencies
within the client's system of care.

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to coordinate with
other individuals and agencies within the client's
system of care affecting one of three clients (#1).
The findings are:

Observation on 2/26/25 at approximately 1:27 pm
of client #1's medication bin revealed:

-There was no Vitamin D3 50 micrograms (mcg)
(Bone health), Atorvastatin 20 milligrams (mg)
(High Cholesterol), Co-Enzyme Q10 200 mg
(Energy) and Omeprazole 20 mg (Heartburn)
available for client #1.

Review on 2/26/25 of client #1's record revealed:

Division of Health Service Regulation
STATE FORM 6899

All staff will receive supervision
training on MAR documentation
to correct the deficient area.
Staff will receive written
documentation from prescribing
physician for any discontinuance
of medicines.

Corrective Measures

The MAR will be signed daily by
staff administering the
medication.Program Manager will
be asked to check for any
unmarked areas or errors on the
MAR daily. Should an error be
identified, the error will be
corrected before staff leaves the
shift. If necessary, supetvisor
will be contacted and medication
errors will be documented as a
Level I incident.

Preventive
Measures

Owner, Program Manager,

Who will Monitor Pharmacy

The MAR will be signed daily by
staff administering the
medication.All MARs will be
audited for completion and
accuracy on a weekly basis by
Owner or Program Manager.All
MARs will be audited by the
distributing pharmacy bi+annually

How Often

QDRS11 If continuation sheet 8 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V179 Continued From page 8

-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

-Physician's orders dated 11/13/24 for the
following medications:

Vitamin D3 50 mcg, one tablet daily
Atorvastatin 20 mg, one tablet daily
Co-Enzyme Q10 200 mg, one capsule daily
Omeprazole 20 mg, one capsule daily

Review on 2/26/25 of MARs for client #1
revealed:

No staff initials to indicate the medication was
administered for the following:

February 2025-

-Vitamin D3 50 mcg on 2/1 thru 2/26
-Atorvastatin 20 mg on 2/7 thru 2/26

-Co-Enzyme Q10 200 mg on 2/7 thru 2/26
-Omeprazole 20 mg on 2/7 thru 2/26

January 2025-

-Vitamin D3 50 mcg on 1/1 thru 1/31

Interview on 2/26/25 with client #1 revealed:
-Some of her medications were not available
because she had to see the doctor to get refills.
-She had blood work completed about a week
ago in order to get one of those medications
refilled.

-She had not taken some of those medications
for most of the month (February 2025).

-She wasn't sure when she would be seeing the
doctor in order to have those medications refilled.
Interview on 2/26/25 with the Program Manager

revealed:

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 9 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V179 Continued From page 9

-Client #1's February and January 2025 MARs
had no staff initials for some of the medications
because she ran out of those medications.

-Some of client #1's medications were not
available because they were waiting on the doctor
to write an order to have those medications
refilled.
-Client #1 required lab work for one of those
medications, which they just recently had done
this month (February 2025).

-She (Program Manager) called the medical

office several times and tried to speak with the
doctor and/or schedule an appointment to get the
medication refilled.
-She was told the doctor was busy or seeing
another patient.

Interview on 2/26/25 with the Director/Qualified

Professional revealed:

-She wasn't aware of some of client #1's
medications not being available.

-"I know medical appointments for clients can be
difficult to make."

-"It all boils down to Medicaid, they have to find
doctors that accept Medicaid."

27G .0603 Incident Response Requirements

0A NCAC 27G .0603 INCIDENT

RESPONSE REQUIREMENTS FOR

CATEGORY A AND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level I, II or III incidents. The policies
shall require the provider to respond by:

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

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

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 10 of 19

PRINTED: 03/03/2025
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

MHLOO1-281

02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

A MOTHER'S LOVE

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

DEFICIENCY)

(x4) ID
PREFIX
TAG

(x5)
COMPLETE
DATE

V 366 Continued From page 10

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

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

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

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,

42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in

Incidents will be reported to IRIS
and MCO within the 72 hour
timeframe.Program Manager will
receive training on how to submit
an icident report with in IRIS.

Corrective
Measures

Within 24 hours of an incident,
the Owner will follow up with the
on-duty staff member to ensure

Paragraph (a) of this
shall address inciden

(c) In addition to the
Paragraph (a) of this
providers, excluding

Rule, ICF/MR providers
ts as required by the federal

regulations in 42 CFR Part 483 Subpart I.

requirements set forth in
Rule, Category A and B
CF/MR providers, shall

Preventive

incident reports are submitted.A
Measures

printout of the submission will be
filed within the facility's filing
system.

develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:
(1)
by:
(A)
(B)
(

(

Who will Monitor

Owner will review IRIS for the
submission of Level II and III
reports into IRIS within in 72
hours as incidents occur,

immediate!

ly securing the client record How Often
obtaining the client record;

making a photocopy;

certifying the copy's completeness; and
transferring the copy to an internal
review team;

(2) convening a meeting of an internal
review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or

C)
D)

Division of Health Service Regulation

STATE FORM 6899 QDRS11 If continuation sheet 110f 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

DEFICIENCY)

A MOTHER'S LOVE

V 366 Continued From page 11

with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows :
(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

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

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

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(8) _ the bhniwbesecher nat resitetsititity
different;

(C)

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

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 12 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

A MOTHER'S LOVE

V 366 Continued From page 12

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by: Based on
record reviews and interviews, the facility failed to
implement a policy governing their response to
Level II incidents as required. The findings are:
Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24. -Diagnoses of Post-
traumatic Stress Disorder, Major Depressive
Disorder and Oppositional Defiant Disorder. -She
was 16 years old. Review on 2/26/25 of client
#3's record revealed: -Admission date of 10/1/24.
-Diagnoses of Adjustment Disorder, Anxiety
Disorder-Unspecified, Attention Deficit
Hyperactivity Disorder. -She was 17 years old.
Review on 2/26/25 of an in-house incident report
dated 12/28/24 revealed: -"On Saturday,
December 28, 2024 at approximately 3:50 PM,
client #1] and [client #3] left the property without
permission. Staff checked the premises and staff
searched the surrounding area _ including
neighborhoods, parks and shopping centers. Staff
contacted the [Name of local police department]
and provided dispatch

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 13 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V 366 Continued From page 13

with the necessary information..."

Review on 2/26/25 of the North Carolina (NC)

Incident Response Improvement System (IRIS)
revealed:

-There was no level II incident report submitted
by the facility for clients #1 and #3 running away
from the facility and the police department being
called by staff.

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

Interview on 2/26/25 with the Program Manager

revealed:

-Clients #1 and #3 ran away from the facility in
December 2024.

-Staff called the police department during that
incident.
-She would normally write up the incident and
email it to the Program Coordinator with their
former agency.

-The Program Coordinator with the former
agency would put the incident into IRIS.

-She confirmed the facility failed to implement a
policy governing their response to Level II
incidents as required.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-She was aware the incident with clients #1 and

#3 running away from the facility in December
2024.

-The Program Coordinator with the former

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 14 of 19

Division of Health Service Regulation

PRINTED: 03/03/2025
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

02/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

A MOTHER'S LOVE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

V 366 Continued From page 14

agency was responsible for putting incidents into
IRIS.

-She confirmed the facility failed to implement a
policy governing their response to Level II
incidents as required.

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

27G .0604 Incident Reporting Requirements

OA NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY A AND B PROVIDERS
(a) Category A and B providers shall report all
level II incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the

Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

inf or mation:

(4) 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

Division of Health Service Regulation

STATE FORM 6899

Incidents will be reported to IRIS
and MCO within the 72 hour
timeframe.Program Manager will
receive training on how to submit
an icident report with in IRIS

Corrective
Measures

Within 24 hours of an incident,
the owner will follow up with the
on-duty staff member to ensure
incident reports are submitted.A
printout of the submission will be
filed within the facility's filing
system.

Preventive
Measures

Who will Monitor

Owner will review IRIS for the
submission of Level II and III
reports into IRIS within in 72
hours as incidents occur.

How Often

QDRS11 If continuation sheet 15 of 19

PRINTED: 03/03/2025
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

MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

A MOTHER'S LOVE

V 367 Continued From page 15

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:

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

(c) Category A and B providers shall submit,

upon request by the LME, other information
obtained regarding the incident, including:

(4) hospital records including confidential
inf or m ation ;

(2) reports by other authorities; and

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

(e) Category A and B providers shall senda
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:

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

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 16 of 19

PRINTED: 03/03/2025

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
MHLOO1-281 B.WING 02/26/2025

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

AMOTHER'S LOVE 1227 WESTMORELAND DRIVE

BURLINGTON, NC 27217

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

DEFICIENCY)

V 367 Continued From page 16

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 reviews and interviews, the
facility failed to ensure incidents were reported to
the Local Management Entity/Managed Care
Organization (LME/MCO) for the catchment area
where services are provided within 72 hours of
becoming aware of the incident. The findings are:
Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

Review on 2/26/25 of client #3's record revealed:
-Admission date of 10/1/24.

-Diagnoses of Adjustment Disorder, Anxiety
Disorder-Unspecified, Attention Deficit
Hyperactivity Disorder.

Division of Health Service Regulation

STATE FORM 6899 QDRS11 If continuation sheet 17 of 19

PRINTED: 03/03/2025
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
MHLOO1-281 B.WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
AMOTHER'S LOVE 1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

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

V 367 Continued From page 17

-She was 17 years old.

Review on 2/26/25 of an in-house incident report

dated 12/28/24 revealed:

-"On Saturday, December 28, 2024 at
approximately 3:50 PM, [client #1] and [client #3]
left the property without permission. Staff
checked the premises and staff searched the
surrounding area including neighborhoods, parks
and shopping centers. Staff contacted the [Name
of local police department] and provided dispatch
with the necessary information..."

Review on 2/26/25 of the North Carolina (NC)

Incident Response Improvement System (IRIS)
revealed:
-There was no level II incident report submitted
by the facility for clients #1 and #3 running away
from the facility and the police department being
called by staff.

Interview on 2/26/25 with the Program Manager

revealed:

-Clients #1 and #3 ran away from the facility in
December 2024.

-Staff called the police department during that
incident.

-She would normally write up the incident and
email it to the Program Coordinator with their
former agency.

-The Program Coordinator with the former
agency would put the incident into IRIS.

-She wasn't sure why the incident with client #1
and #3 running away was not in IRIS.

-She confirmed the facility failed to report the
above incident to LME/MCO within 72 hours.

Interview on 2/26/25 with the Director/Qualified

Professional revealed:
-She was aware the incident with clients #1 and

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 18 of 19

Division of Health Service Regulation

PRINTED: 03/03/2025
FORM APPROVED

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

MHLOO1-281

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

02/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

A MOTHER'S LOVE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

DEFICIENCY)

(x5)
COMPLETE
DATE

V 367 Continued From page 18

#3 running away from the facility in December
2024.

-The Program Coordinator with the former

agency was responsible for putting incidents into
IRIS.

-She was not sure why the incident with clients #1.
and #3 was not in IRIS.

-"I just have to eat that citation."

-She confirmed the facility failed to report the
above incident to LME/MCO within 72 hours.

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

Division of Health Service Regulation
STATE FORM 6899

QDRS11

If continuation sheet 19 of 19

document_type: Plan of Correction