facility_name: Fairview House

summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 07/24/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED

MHLO011-259 B.MANG. 07/23/2025

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

FAIRVIEW HOUSE
FAIRVIEW, NC 28730

(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)

T
V 000 INITIAL COMMENTS Vv 000

An annual survey was completed on July 23, |
2025 A deficiency wase cited

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

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

RECEIVED

V 114 27G .0207 Emergency Plans and Supplies | Vv 114 AUG 0 7

10A NCAC 27G 0207 EMERGENCY PLANS | DHSR. MH Li
AND SUPPLIES “MH Licensure Sect
(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
request. The plans shall include evacuation

procedures and routes

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

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. |
Drills shall be conducted under conditions that
simulate 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 RIREGTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
5 aol i Quality Assurance Coordinator 8/4/2025
STATE FORM 6208 Q6BF11 If continuation sheet 1 of 3

BCODES4B5029486

PRINTED: 07/24/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X01) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(3) DATE SURVEY

A BUILDING COMPLETED

MHLO11-259 8 WING _____H 07/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW, NC 28730

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (x5)

FAIRVIEW HOUSE

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)
—T

Vv 114 Continued From page 1 vi14 |

This Rule is not met as evidenced by | |
Based on record review and interviews, the

facility failed to ensure fire and disaster drills were |
held at least quarterly and repeated for each shift |
The findings are

Review on 7/23/25 of facility fire and disaster |
drills revealed

-No fire drills on second shift for first quarter 2025
(January, February, March). |
-No fire drills on second shift for second quarter |
2025 (April, May, June).

-No disaster drills on first shift for first quarter
2025 (January, February, March)

-No disaster drills on first shift for second quarter
2025 (April, May, June)

Interviews on 7/23/25 with Clients #1 and #2 |
revealed:

-Participated in fire and disaster drills.
-Knew where to go during drills.

Interview on 7/23/25 with Staff #1 revealed: |
-Fire and disaster drills were completed monthly | |

Interview on 7/23/25 with Staff #2 revealed
-Fire and disaster drills were done once or twice a
month

Interview on 7/23/25 with the House Manager
revealed:

-Was not aware that drills needed to be done on |
each shift ..."if | did, would have had them done
that way." |
-Would complete them on each shift moving
forward

Interview on 7/23/25 with the Qualified

Professional revealed:

-"We have all staff doing them. Thought we were
Division of Health Service Regulation

STATE FORM 000 aearit it continuation sheet 2 of 3

Division of Health Service Regulation

PRINTED: 07/24/2025
FORM APPROVED

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

MHL011-259

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

NAME OF PROVIDER OR SUPPLIER

FAIRVIEW HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE
FAIRVIEW, NC 28730

(3) DATE SURVEY
COMPLETED

07/23/2025

SUMMARY STATEMENT OF DEFICIENCIES.

PROVIDER'S PLAN OF CORRECTION

(xs)

rotating them .. everyone is responsible."

-She and the House Manager provided oversight
for the drills

-We even practice going out of different exits."
-Communication got a little broken down."

(X4) 1D 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)
Vv 114 Continued From page 2 v114

| To ensure there are no future
discrepancies with how and when

| drills are conducted in our
licensed programs, we have

| adjusted our process.

Going forward, whenever a drill is

| completed, our Director of Quality
& Compliance (DQC) is notified.

| The DQC passes that information
along to the regional Quality

| Assurance Coordinator (QAC)

| responsible for the group home or

day program

When there are two weeks left in

a quarter, the QAC will identify

which types of drill(s) still need to

be conducted and by which shift.

The QAC will work with the

residential coordinator to get the

drills scheduled and completed.

This will ensure no future gaps in

reporting.

All drill data will be stored in

| Smartsheet and can be shared

with any DHSR reviewers in the

| licensed program review.

This process will be explained to

all licensed program directors and

leads in an upcoming training that

is scheduled for August 8th

Division of Health Service Regulation
STATE FORM

Q6BF11

Licensed
program
coordinator,
and lead staff
will be trained
about this

process on
8/8/2025 and
to put into
practice

ongoingly

If continuation sheet 3 of 3


state: NC

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 05/28/2024

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO011-259 05/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on May 23,
2024. No deficiencies were cited.

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

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

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

STATE FORM

6899

LUWR11

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-259

PRINTED: 03/10/2022

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
B.WING 03/02/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed on 3/2/22. No
deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Intellectual/Developmental
Disabilities.
The survey sample consisted of audits of 3
current clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899 56VW11 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual 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

MHLO011-259

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/07/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
05/31/2019

An annual and follow up survey was completed
on 5/31/19. No deficiencies were cited.

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

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

STATE FORM

6899

6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


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

raw_content:
PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

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

R
MHL011-259 B. WING _____ 05/25/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW, NC 28730

(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)

FAIRVIEW HOUSE

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed RECEIVED
on 5/25/18. Deficiencies were cited. By MH Lic & Cert Section at 3:27 pm, Jun 28, 2018

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

V 117| 27G .0209 (B) Medication Requirements V117 | Residential Coordinator will complete a weekly

checklist to ensure that expired medications
10A NCAC 27G .0209 MEDICATION have been appropirately discarded, that the

REQUIREMENTS MAR matches doctor's orders, and to attest
(b) Medication packaging and labeling: that no documentation issues have occurred, 6/24/18 &
(1) Non-prescription drug containers not incuding administrative record errors and ongoing
dispensed by a pharmacist shall retain the incident reporting. This checklist, and a
manufacturer's label with expiration dates clearly copy/scan of all MARs, will be securely
visible; emailed to the Regional Director weekly for
(2) Prescription medications, whether purchased review.

or obtained as samples, shall be dispensed in
tamper-resistant packaging that will minimize the
tisk of accidental ingestion by children. Such
packaging includes plastic or glass bottles/vials
with tamper-resistant caps, or in the case of
unit-of-use packaged drugs, a zip-lock plastic bag
may be adequate;

(3) The packaging label of each prescription
drug dispensed must include the following:

(A) the client's name;

(B) the prescriber's name;

(C) the current dispensing date;

(D) clear directions for self-administration;

(E) the name, strength, quantity, and expiration
date of the prescribed drug; and

(F) the name, address, and phone number of the
pharmacy or dispensing location (e.g., mh/dd/sa
center), and the name of the dispensing
practitioner.

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

Quality Assurance Coordinator 6/26/18
STATE FORM 6899 NIVX11 If continuation sheet 1 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 117] Continued From page 1 V 117

This Rule is not met as evidenced by:

Based on observations, interviews, and record
review, the facility failed to ensure all prescription
medications available for administration were not
expired and contained a current dispensing date
for 2 of 3 clients (Clients #1and #3). The findings
are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Order dated 2/14/18 for Diazepam 5mg 2-3 tabs
every 6 hours as needed.
-Order dated 2/14/18 for Risperidone 1mg every
6 hours for agitation.

Record review on 5/24/18 for Client #3 revealed:
-Admission date of 11/1/04 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Stevens - Johnson syndrome, Anxiety Disorder,
Seizure Disorder, High Cholesterol and Acid
Reflux.
Order dated 9/12/16 for Azelastine 137mcg 2
sprays each nostril twice daily.
Order dated 2/2/18 for Ammonium Lactate 12 %
cream apply to foot twice daily.
Order dated 9/12/16 for APAP (acetaminophen)
500mg administer as directed.

Observation at 10:30am on 5/24/18 revealed:
-Client #1 medication box contained:

--1 bubble pack of Diazepam 5mg containing 6
tablets dispensed on 1/4/17 with an expiration
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 2 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE FAIRVIEW, NC 28730
(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 117] Continued From page 2 V 117
date 1/4/18.
--1 bubble pack of Risperidone 1mg containing
52 tablets dispensed on 12/31/16 expiring on
12/31/17.
-Client #3 medication box contained:
--1 bottle of Azelastine 137mcg with no label with
client name, instructions, prescriber, dispense
date, or pharmacy information as required.
--1 tube of Ammonium Lactate 12% cream with
no label with client name, instructions, prescriber,
dispense date, or pharmacy information as
required.
--1 bubble pack of APAP 500mg containing 60
tablets dispensed on 10/9/16 expiring on 10/9/17.
V 118} 27G .0209 (C) Medication Requirements V 118 In addition to the checks & balances proposed

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

Division of Health Service Regulation
STATE FORM

6899

for the Residential Coordinator, the Regional
Director will provide oversight in the following
ways:

- Review Residential Coordinator's weekly
checklist

- Review MARs weekly

- Confirm MARs are uploaded to each
client's Electronic Heath Record (EHR) at the
end of each month

- Visit Fairview once a month for review of
medication storage, process, and practices.

- Complete a monthly phone conference
with the Director of Services, or Associate
Director of Services, regarding the status of
this plan of correction

6/24/18 &
ongoing

Further, the Senior Residential Coordinator will
offer support to Fairview by in-person visits
every other month to teach, train, and be
involved in goup home staff meetings.

Additionally, each of our two group homes in
Western, NC will conduct quarterly internal
audits of one another.

NIVX11 If continuation sheet 3 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

DEFICIENCY)
V 118) Continued From page 3 Vv 118 Finally, ASNC Quality Management will
. . woe . conduct an internal survey, biannually to serve
(C) instructions for administering the drug; ra y y 6/24/18 &
. . - . as a training tool and to enhance staff ongoing
(D) date and time the drug is administered; and expectations.
(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to keep the MAR current and failed
to follow the written order of a physician affecting
3 of 3 clients (Client #1, Client #2 and Client #3).
The findings are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Physician ordered medications included:
--Benztropine 1mg (tremors) twice daily.
--Celexa 20mg (depression) 1.5 tabs at bedtime.
--Divalproex ER 500mg (seizures) 2 tabs at
bedtime.

--Risperidone (antipsychotic) 2mg at bedtime.
Review on 5/24/18 of March-May 2018 MARs
revealed:

--Benztropine was not initialed as administered on
4/29/18 am dose and 4/30/18 pm dose.

--Celexa 20mg was not initialed as administered
on 4/30/18 pm dose.

--Divalproex ER was not initialed as administered
on 4/30/18 pm dose.

--Risperidone was not initialed as administered
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 4 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

on 4/30/18 pm dose.

Record review on 5/24/18 for Client #2 revealed:
-Admission date of 8/17/10 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Depressive Disorder and Anxiety Disorder.
-Physician ordered medications included:

--Vicks Vapor Rub (fungus) apply to toenails daily.
--Lamisil 1% spray (fungus) apply 1 spray to each
foot twice daily.

Review on 5/24/18 of March-May 2018 MARs
revealed:

--Vicks Vapor Rub was not initialed as
administered on 5/21/18 am dose.

--Lamisil was not initialed as administered on
5/21/18 am dose.

Record review on 5/24/18 for Client #3 revealed:
-Admission date of 11/1/04 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Stevens - Johnson syndrome, Anxiety Disorder,
Seizure Disorder, High Cholesterol and Acid
Reflux.

-Physician ordered medications included:
--Azelastine 137mcg (antihistamine) 2 sprays
each nostril twice daily.

--Ranitidine 150mg (antacid) twice daily.
--Phenobarbital 64.8mg (seizures) twice daily.
--Ammonium Lactate 12% cream (dry skin) apply
to foot twice daily.

--Fluorometholone 0.1% (eyes) 1 drop in each
eye twice daily.

--Caltrate 600 +D (bones) chew twice daily.
--Restasis 0.05% (eyes) 1 drop in each eye twice
daily.

--Risperidone 1mg (antipsychotic) at bedtime.
--Systane Eye Drops 0.3/.4 (eyes) 1 drop each
eye every 4 hours.

--Metamucil (constipation) 1 packet daily.
--Risperidone 0.5mg (antipsychotic) 1.5 tabs in
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 5 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

the AM was ordered 7/13/16. This 0.5mg was
decreased to 1 tab in AM on 2/2/18 and
decreased again to 0.25mg once in AM on 5/9/18.
Review on 5/24/18 of March-May 2018 MARs
revealed:

--Azelastine was not initialed as administered on
4/30/18 pm dose.

--Ranitidine was not initialed as administered on
4/30/18 pm dose.

--Phenobarbital was not initialed as administered
on 4/30/18 pm dose.

--Ammonium Lactate was not initialed as
administered on 4/30/18 pm dose.
--Fluorometholone was not initialed as
administered on 4/30/18 pm dose.

--Caltrate was not initialed as administered on
4/30/18 pm dose.

--Restasis was not initialed as administered on
4/30/18 pm dose.

--Risperidone was not initialed as administered
on 4/30/18.

--Systane Eye Drops was not initialed as
administered on 3/31/18 12pm and 4pm doses,
4/28/18 12pm and 4pm doses; 4/29/18 12pm
dose, 4/30/18 8pm dose and 5/20/18 12pm dose.
--Metamucil was ordered on 4/25/18 and
dispensed on 4/25/18 but was not administered
until 5/2/18.

--Risperidone 0.25mg was ordered on 5/9/18 and
dispensed on 5/9/18 but had not been
administered at all.

Attempts to interview the pharmacist were
unsuccessful.

Interview on 5/24/18 with the Qualified
Professional (QP) revealed:

-He had already spoken to the primary staff who
had forgotten to document administering most of
the medications. Staff had passed meds but had
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 6 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

DEFICIENCY)
V 118| Continued From page 6 V 118

just forgotten to document the MAR.

-He was responsible for taking clients to doctors'
appointments and was aware when medications
were changed.

-He was responsible for checking to make sure
medications matched the MARs weekly. He did
not know how this slipped.

-Staff checked in meds when they were delivered
at night. If a new medication was received it
should have been written on the MAR.

-He had written on the February MAR for Client
#3 the change to decrease the Risperidone from
the 1.5 tab to 1 tab in the morning. Staff were
leaving the remaining % tab in the bubble pack
and taping the backside. The QP returned all
unused meds to the pharmacy but did not keep a
record of what was returned.

-The March MAR from the pharmacy still
indicated 1.5 tabs of Risperidone and not the
lower AM dose and he forgot to change MAR.
-The pharmacy kept sending 1.5 tabs of the 0.5
mg Risperidone as well as indicating this amount
on the April and May MARs. The QP did not
change the MARs or contact the pharmacy
regarding the order change.

-He tried to contact the psychiatrist to inform him
the Risperidone had not been reduced as
ordered. He would continue to follow up.

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

V 123) 27G .0209 (H) Medication Requirements V 123 All staff will be re-trained on appropriate
incident reporting procedures by ASNC's
10A NCAC 27G .0209 MEDICATION Quality Management Department.
REQUIREMENTS by 7/31/18

Reports found to be outside of reporting
deadlines or requirements will result in an
internal plan of correction.

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

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 7 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to immediately notify a physician or
pharmacist of medication errors for 1 of 3 clients
(Client #1). The findings are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Physician ordered medications included:
--Diazepam 5mg (anxiety) 2-3 tabs every 6 hours
as needed.

--Diazepam 5mg (anxiety) % tab twice daily.

Review on 5/24/18 of Incident Reports from
1/1/18-5/21/18 revealed:

-One- Medication Error/Level 1 incident report for
Client #1 on 5/17/18 when he was given the
wrong dose of Diazepam. Staff had given Client
#1 the PRN dose rather than his daily dose. She
had contacted the QP.

-No indication pharmacist or physician were
notified.

Interview on 5/24/18 with the QP revealed:
-Staff contacted him on 5/17/18 regarding the
wrong dose. He contacted the pharmacist but
had not documented this.

-No documentation was available to verify

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123} Continued From page 7 V 123

6899

NIVX11

If continuation sheet 8 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123] Continued From page 8 V 123
pharmacy contact immediately following wrong
medication dosage taken by Client #1.
V 133} G.S. 122C-80 Criminal History Record Check V 133

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private

Division of Health Service Regulation
STATE FORM

6899

Review current process for background
completion, to include fingerprinting

requirement for all candidates who have
resided in NC less than 5 years, with all
staffing specialists throughout the state.

Re-educate all staffing specialists throughout
the State of fingerprinting requirement, how to | 6/27/18
obtain, and deadlines associated with this
requirement.

Re-educate all staffing specialists throughout
the State of the background process in place
for storage and maintenance of background
results.

Monthly audit of 100% of new hires for
compliance with background & fingerprinting ongoing
requirements.

NIVX11 If continuation sheet 9 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 9 V 133

entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 10 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

(3) The age of the person at the time of the
conviction.

(4) The circumstances surrounding the
commission of the crime, if known.

(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled.

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.

(e) Relevant Offense. - As used in this section,

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 10 V 133

6899

NIVX11

If continuation sheet 11 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

“relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
njury or Damage by Use of Explosive or
ncendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
ntoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 11 V 133

6899

NIVX11

If continuation sheet 12 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on personnel file review and staff
interviews, the facility failed to obtain fingerprints
when completing a national criminal background
check for applicants who had lived in North
Carolina less than 5 years prior to employment
for 1 of 3 sampled staff (Staff #2). The findings
are:

Record review on 5/24/18 for Staff #2 revealed:

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133} Continued From page 12 V 133

6899

NIVX11

If continuation sheet 13 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

(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 133] Continued From page 13 V 133

-Date of hire- 9/25/17
-Criminal background check was completed
9/7/18 but did not include SBI fingerprints.

Interview on 5/24/18 with Staff #2 revealed:
-He moved from Florida August 2017.

-He did not remember completing fingerprint
check when hired.

Interview on 5/25/18 with regional Human
Resources (HR) Director revealed:

-She began in HR in December 2017 and was not
aware if fingerprints were done for Staff #2.

-She could not find evidence of SBI report in
electronic file.

-The Licensee's HR Director reported the
fingerprint requirement for Staff #2 had slipped
through the cracks.

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 14 of 14

Ke Autism Society

of NORTH CAROLINA

Residential Services: Weekly Checklist

Week of: Sunday, June 24, 2018

Participant Name: Record Number:
New or Changed Doctor’s Orders: Medication has changed [_| Yes or [_|No
Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

MAR Updated? (1 Yes or LJ No

MAR Updated? 1 Yes or LJ No

New or Changed PRNs: Medication has changed (_| Yes or |_| No

Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

Were any medications needing refills? Refills | Yes or _|No
Date:
Time:
Pick-up by:

Printed name: Signature:

Were any medications discarded/properly disposed of? Discarded Meds [_| Yes or _|No
Date:
Method:

Were there any incident reports this week? Incident Reports _| Yes or |_| No
Type: Date: Time:

Were these sent to QM? Yes or | No

Submission Date:

By signing, | attest that | have reviewed all the information associated with this client and that the
above information is accurate.

Signature of Residential Coordinator Date

Signature of Regional Director Date

Page 1 of 3

Ke Autism Society

of NORTH CAROLINA

Residential Services: Weekly Checklist

Week of: Sunday, June 24, 2018

Participant Name: Record Number:
New or Changed Doctor’s Orders: Medication has changed [_| Yes or [_|No
Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

MAR Updated? (1 Yes or LJ No

MAR Updated? 1 Yes or LJ No

New or Changed PRNs: Medication has changed (_| Yes or |_| No

Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

Were any medications needing refills? Refills | Yes or _|No
Date:
Time:
Pick-up by:

Printed name: Signature:

Were any medications discarded/properly disposed of? Discarded Meds [_| Yes or _|No
Date:
Method:

Were there any incident reports this week? Incident Reports _| Yes or |_| No
Type: Date: Time:

Were these sent to QM? Yes or | No

Submission Date:

By signing, | attest that | have reviewed all the information associated with this client and that the
above information is accurate.

Signature of Residential Coordinator Date

Signature of Regional Director Date

Page 2 of 3

Ke Autism Society

of NORTH CAROLINA

Residential Services: Weekly Checklist

Week of: Sunday, June 24, 2018

Participant Name: Record Number:
New or Changed Doctor’s Orders: Medication has changed [_| Yes or [_|No
Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

MAR Updated? (1 Yes or LJ No

MAR Updated? 1 Yes or LJ No

New or Changed PRNs: Medication has changed (_| Yes or |_| No

Effective Date: New Order:

MAR Updated? 1 Yes or (| No

MAR Updated? (1 Yes or (| No

Were any medications needing refills? Refills | Yes or _|No
Date:
Time:
Pick-up by:

Printed name: Signature:

Were any medications discarded/properly disposed of? Discarded Meds [_| Yes or _|No
Date:
Method:

Were there any incident reports this week? Incident Reports _| Yes or |_| No
Type: Date: Time:

Were these sent to QM? Yes or | No

Submission Date:

By signing, | attest that | have reviewed all the information associated with this client and that the
above information is accurate.

Signature of Residential Coordinator Date

Signature of Regional Director Date

Page 3 of 3

document_type: Plan of Correction


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

raw_content:
Division

STATEMENT OF DEFICIENCIES

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(b) Medication packaging
(1) Non-prescription drug containers not
dispensed by a pharmacist shall retain the
manufacturer's label with expiration dates clearly
visible;

(2) Prescription medications, whether purchased
or obtained as samples, shall be dispensed in
tamper-resistant packaging that will minimize the
tisk of accidental ingestion by children. Such
packaging includes plastic or glass bottles/vials
with tamper-resistant caps, or in the case of
unit-of-use packaged drugs, a zip-lock plastic bag
may be adequate;

(3) The packaging label of each prescription
drug dispensed must include the following:

(A) the client's name;

(B) the prescriber's name;

(C) the current dispensing date;

(D) clear directions for self-administration;

(E) the name, strength, quantity, and expiration
date of the prescribed drug; and

(F) the name, address, and phone number of the
pharmacy or dispensing location (e.g., mh/dd/sa
center), and the name of the dispensing
practitioner.

and labeling:

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

STATE FORM

6899

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE FAIRVIEW, NC 28730
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual and follow up survey was completed
on 5/25/18. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Intellectual and
Developmental Disabilities.
V 117| 27G .0209 (B) Medication Requirements V 117

NIVX11

TITLE (X6) DATE

If continuation sheet 1 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 117] Continued From page 1 V 117

This Rule is not met as evidenced by:

Based on observations, interviews, and record
review, the facility failed to ensure all prescription
medications available for administration were not
expired and contained a current dispensing date
for 2 of 3 clients (Clients #1and #3). The findings
are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Order dated 2/14/18 for Diazepam 5mg 2-3 tabs
every 6 hours as needed.
-Order dated 2/14/18 for Risperidone 1mg every
6 hours for agitation.

Record review on 5/24/18 for Client #3 revealed:
-Admission date of 11/1/04 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Stevens - Johnson syndrome, Anxiety Disorder,
Seizure Disorder, High Cholesterol and Acid
Reflux.
Order dated 9/12/16 for Azelastine 137mcg 2
sprays each nostril twice daily.
Order dated 2/2/18 for Ammonium Lactate 12 %
cream apply to foot twice daily.
Order dated 9/12/16 for APAP (acetaminophen)
500mg administer as directed.

Observation at 10:30am on 5/24/18 revealed:
-Client #1 medication box contained:

--1 bubble pack of Diazepam 5mg containing 6
tablets dispensed on 1/4/17 with an expiration
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 2 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-259

6 LANNIN

FAIRVIEW HOUSE

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

|G DRIVE

FAIRVIEW, NC 28730

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/25/2018

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 117

Vv 118

Continued From page 2

date 1/4/18.

--1 bubble pack of Risperidone 1mg containing
52 tablets dispensed on 12/31/16 expiring on
12/31/17.

-Client #3 medication box contained:

--1 bottle of Azelastine 137mcg with no label with
client name, instructions, prescriber, dispense
date, or pharmacy information as required.

--1 tube of Ammonium Lactate 12% cream with
no label with client name, instructions, prescriber,
dispense date, or pharmacy information as
required.

--1 bubble pack of APAP 500mg containing 60
tablets dispensed on 10/9/16 expiring on 10/9/17.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

Division of Health Service Regulation
STATE FORM

V 117

V 118

6899

NIVX11

If continuation sheet 3 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

DEFICIENCY)
V 118| Continued From page 3 V 118

(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
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 and failed
to follow the written order of a physician affecting
3 of 3 clients (Client #1, Client #2 and Client #3).
The findings are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Physician ordered medications included:
--Benztropine 1mg (tremors) twice daily.
--Celexa 20mg (depression) 1.5 tabs at bedtime.
--Divalproex ER 500mg (seizures) 2 tabs at
bedtime.

--Risperidone (antipsychotic) 2mg at bedtime.
Review on 5/24/18 of March-May 2018 MARs
revealed:

--Benztropine was not initialed as administered on
4/29/18 am dose and 4/30/18 pm dose.

--Celexa 20mg was not initialed as administered
on 4/30/18 pm dose.

--Divalproex ER was not initialed as administered
on 4/30/18 pm dose.

--Risperidone was not initialed as administered
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 4 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

on 4/30/18 pm dose.

Record review on 5/24/18 for Client #2 revealed:
-Admission date of 8/17/10 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Depressive Disorder and Anxiety Disorder.
-Physician ordered medications included:

--Vicks Vapor Rub (fungus) apply to toenails daily.
--Lamisil 1% spray (fungus) apply 1 spray to each
foot twice daily.

Review on 5/24/18 of March-May 2018 MARs
revealed:

--Vicks Vapor Rub was not initialed as
administered on 5/21/18 am dose.

--Lamisil was not initialed as administered on
5/21/18 am dose.

Record review on 5/24/18 for Client #3 revealed:
-Admission date of 11/1/04 with diagnoses of
Autism, OCD, Moderate Intellectual Disability,
Stevens - Johnson syndrome, Anxiety Disorder,
Seizure Disorder, High Cholesterol and Acid
Reflux.

-Physician ordered medications included:
--Azelastine 137mcg (antihistamine) 2 sprays
each nostril twice daily.

--Ranitidine 150mg (antacid) twice daily.
--Phenobarbital 64.8mg (seizures) twice daily.
--Ammonium Lactate 12% cream (dry skin) apply
to foot twice daily.

--Fluorometholone 0.1% (eyes) 1 drop in each
eye twice daily.

--Caltrate 600 +D (bones) chew twice daily.
--Restasis 0.05% (eyes) 1 drop in each eye twice
daily.

--Risperidone 1mg (antipsychotic) at bedtime.
--Systane Eye Drops 0.3/.4 (eyes) 1 drop each
eye every 4 hours.

--Metamucil (constipation) 1 packet daily.
--Risperidone 0.5mg (antipsychotic) 1.5 tabs in
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 5 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

the AM was ordered 7/13/16. This 0.5mg was
decreased to 1 tab in AM on 2/2/18 and
decreased again to 0.25mg once in AM on 5/9/18.
Review on 5/24/18 of March-May 2018 MARs
revealed:

--Azelastine was not initialed as administered on
4/30/18 pm dose.

--Ranitidine was not initialed as administered on
4/30/18 pm dose.

--Phenobarbital was not initialed as administered
on 4/30/18 pm dose.

--Ammonium Lactate was not initialed as
administered on 4/30/18 pm dose.
--Fluorometholone was not initialed as
administered on 4/30/18 pm dose.

--Caltrate was not initialed as administered on
4/30/18 pm dose.

--Restasis was not initialed as administered on
4/30/18 pm dose.

--Risperidone was not initialed as administered
on 4/30/18.

--Systane Eye Drops was not initialed as
administered on 3/31/18 12pm and 4pm doses,
4/28/18 12pm and 4pm doses; 4/29/18 12pm
dose, 4/30/18 8pm dose and 5/20/18 12pm dose.
--Metamucil was ordered on 4/25/18 and
dispensed on 4/25/18 but was not administered
until 5/2/18.

--Risperidone 0.25mg was ordered on 5/9/18 and
dispensed on 5/9/18 but had not been
administered at all.

Attempts to interview the pharmacist were
unsuccessful.

Interview on 5/24/18 with the Qualified
Professional (QP) revealed:

-He had already spoken to the primary staff who
had forgotten to document administering most of
the medications. Staff had passed meds but had
Division of Health Service Regulation

STATE FORM 6899 NIVX11 If continuation sheet 6 of 14

PRINTED: 06/18/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

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

DEFICIENCY)
V 118| Continued From page 6 V 118

just forgotten to document the MAR.

-He was responsible for taking clients to doctors'
appointments and was aware when medications
were changed.

-He was responsible for checking to make sure
medications matched the MARs weekly. He did
not know how this slipped.

-Staff checked in meds when they were delivered
at night. If a new medication was received it
should have been written on the MAR.

-He had written on the February MAR for Client
#3 the change to decrease the Risperidone from
the 1.5 tab to 1 tab in the morning. Staff were
leaving the remaining % tab in the bubble pack
and taping the backside. The QP returned all
unused meds to the pharmacy but did not keep a
record of what was returned.

-The March MAR from the pharmacy still
indicated 1.5 tabs of Risperidone and not the
lower AM dose and he forgot to change MAR.
-The pharmacy kept sending 1.5 tabs of the 0.5
mg Risperidone as well as indicating this amount
on the April and May MARs. The QP did not
change the MARs or contact the pharmacy
regarding the order change.

-He tried to contact the psychiatrist to inform him
the Risperidone had not been reduced as
ordered. He would continue to follow up.

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

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

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

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 7 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to immediately notify a physician or
pharmacist of medication errors for 1 of 3 clients
(Client #1). The findings are:

Record review on 5/24/18 for Client #1 revealed:
-Admission date of 9/1/04 with diagnoses of
Autism, Obsessive Compulsive Disorder (OCD),
Intermittent Explosive Disorder, Mild Intellectual
Disability and Seizure Disorder.

-Physician ordered medications included:
--Diazepam 5mg (anxiety) 2-3 tabs every 6 hours
as needed.

--Diazepam 5mg (anxiety) % tab twice daily.

Review on 5/24/18 of Incident Reports from
1/1/18-5/21/18 revealed:

-One- Medication Error/Level 1 incident report for
Client #1 on 5/17/18 when he was given the
wrong dose of Diazepam. Staff had given Client
#1 the PRN dose rather than his daily dose. She
had contacted the QP.

-No indication pharmacist or physician were
notified.

Interview on 5/24/18 with the QP revealed:
-Staff contacted him on 5/17/18 regarding the
wrong dose. He contacted the pharmacist but
had not documented this.

-No documentation was available to verify

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 123} Continued From page 7 V 123

6899

NIVX11

If continuation sheet 8 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-259

6 LANNIN

FAIRVIEW HOUSE

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

|G DRIVE

FAIRVIEW, NC 28730

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
05/25/2018

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private

Division of Health Service Regulation
STATE FORM

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

DEFICIENCY)
V 123] Continued From page 8 V 123
pharmacy contact immediately following wrong
medication dosage taken by Client #1.
V 133} G.S. 122C-80 Criminal History Record Check V 133

6899

NIVX11

If continuation sheet 9 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 9 V 133

entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 10 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

(3) The age of the person at the time of the
conviction.

(4) The circumstances surrounding the
commission of the crime, if known.

(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled.

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.

(e) Relevant Offense. - As used in this section,

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 10 V 133

6899

NIVX11

If continuation sheet 11 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

“relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
njury or Damage by Use of Explosive or
ncendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
ntoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133] Continued From page 11 V 133

6899

NIVX11

If continuation sheet 12 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/18/2018
FORM APPROVED

(X3) DATE SURVEY

violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on personnel file review and staff
interviews, the facility failed to obtain fingerprints
when completing a national criminal background
check for applicants who had lived in North
Carolina less than 5 years prior to employment
for 1 of 3 sampled staff (Staff #2). The findings
are:

Record review on 5/24/18 for Staff #2 revealed:

Division of Health Service Regulation
STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-259 B. WING 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6 LANNING DRIVE
FAIRVIEW HOUSE
FAIRVIEW, NC 28730
(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 133} Continued From page 12 V 133

6899

NIVX11

If continuation sheet 13 of 14

PRINTED: 06/18/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-259 B. WING ____ 05/25/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6 LANNING DRIVE

FAIRVIEW HOUSE FAIRVIEW, NC 28730

(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 133] Continued From page 13 V 133

-Date of hire- 9/25/17
-Criminal background check was completed
9/7/18 but did not include SBI fingerprints.

Interview on 5/24/18 with Staff #2 revealed:
-He moved from Florida August 2017.

-He did not remember completing fingerprint
check when hired.

Interview on 5/25/18 with regional Human
Resources (HR) Director revealed:

-She began in HR in December 2017 and was not
aware if fingerprints were done for Staff #2.

-She could not find evidence of SBI report in
electronic file.

-The Licensee's HR Director reported the
fingerprint requirement for Staff #2 had slipped
through the cracks.

Division of Health Service Regulation
STATE FORM 6899 NIVX11 If continuation sheet 14 of 14

document_type: Statement of Deficieny


facility_name: Meadow View Home

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL012-154

PRINTED: 12/17/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING: COMPLETED
B.WING 12/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

111 MEADOW VIEW STREET

MEADOW VIEW HOME
MORGANTON, NC 28655
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed on 12/17/25.
No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living for Individuals of all Disability
Groups/Alternative Family Living.
The facility is licensed for 3 and has a current
census of 3. The survey sample consisted of an
audit of 3 clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899 UY8T11 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 11/15/2024

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL012-154 — 11/15/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 MEADOW VIEW STREET
MEADOW VIEW HOME
MORGANTON, NC 28655
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on November
15, 2024. No deficiencies cited.

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

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

This Statement of Deficiencies was amended on
November 15, 2024 due to additional information
regarding licensure category. Rule 10A NCAC
27G .5601 Scope (Tag V289) was deleted.

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

STATE FORM 6609 YEY611 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL012-154

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

111 MEADOW VIEW STREET

PRINTED: 11/07/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

11/06/2024

10A NCAC 27G .5601 SCOPE

(a) Supervised living is a 24-hour facility which
provides residential services to individuals in a
home environment where the primary purpose of
these services is the care, habilitation or
rehabilitation of individuals who have a mental
illness, a developmental disability or disabilities,
or a substance abuse disorder, and who require
supervision when in the residence.

(b) A supervised living facility shall be licensed if
the facility serves either:

(1) one or more minor clients; or

(2) two or more adult clients.

Minor and adult clients shall not reside in the
same facility.

(c) Each supervised living facility shall be
licensed to serve a specific population as
designated below:

(1) "A" designation means a facility which
serves adults whose primary diagnosis is mental
illness but may also have other diagnoses;

(2) "B" designation means a facility which
serves minors whose primary diagnosis is a
developmental disability but may also have other
diagnoses;

(3) "C" designation means a facility which

Division of Health Service Regulation

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

STATE FORM

6808 YEY611

TITLE

MEADOW VIEW HOME
MORGANTON, NC 28655
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual survey was completed on November 6,
2024. A deficiency was cited.
This facility is licensed for the following service
category: 10A NCAC .5600C Supervised Living
for Adults with Developmental Disability.
This facility is licensed for 3 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.
V 289] 27G .5601 Supervised Living - Scope V 289

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL012-154

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

111 MEADOW VIEW STREET
MORGANTON, NC 28655

MEADOW VIEW HOME

PRINTED: 11/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

11/06/2024

serves adults whose primary diagnosis is a
developmental disability but may also have other
diagnoses;

(4) "D" designation means a facility which
serves minors whose primary diagnosis is
substance abuse dependency but may also have
other diagnoses;

(5) "E" designation means a facility which
serves adults whose primary diagnosis is
substance abuse dependency but may also have
other diagnoses; or

(6) "F" designation means a facility ina
private residence, which serves no more than
three adult clients whose primary diagnoses is
mental illness but may also have other
disabilities, or three adult clients or three minor
clients whose primary diagnoses is
developmental disabilities but may also have
other disabilities who live with a family and the
family provides the service. This facility shall be
exempt from the following rules: 10A NCAC 27G
0201 (a)(1),(2),(3),(4),(5)(A)&(B); (6); (7)
(A).(B).(E).(F).(G).(H); (8); (11); (13); (15); (16);
(18) and (b); 10A NCAC 27G .0202(a),(d),(g)(1)
(i); 10A NCAC 27G .0203; 10A NCAC 27G .0205
(a),(b); 10A NCAC 27G .0207 (b),(c); 10A NCAC
27G .0208 (b),(e); 10A NCAC 27G .0209[(c)(1) -
non-prescription medications only] (d)(2),(4); (e)
(1)(A),(D),(E);(f);(g); and 10A NCAC 27G .0304
(b)(2),(d)(4). This facility shall also be known as
alternative family living or assisted family living
(AFL).

This Rule is not met as evidenced by:
Based on record review and interviews, the

Division of Health Service Regulation
STATE FORM

6809

YEY611

(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 289] Continued From page 1 V 289

If continuation sheet 2 of 4

Division of Health Service Regulation

PRINTED: 11/07/2024

FORM APPROVED

facility failed to operate within the scope of
licensure and served as the private residence for
1 of 2 audited staff (Alternative Family Living
(AFL) Provider #1). The findings are:

Review on 11/6/24 of AFL Provider #1's personnel
record revealed:
-Date of hire: 10/15/22.

Interview on 11/5/24 with AFL Provider #1
revealed:

-The facility was her personal residency.

-She received mail at the facility.

-The facility was previously licensed under 10A
NCAC 27G .5600F Supervised Living for
Alternative Family Living (5600F) in 2021.

-The facility went under the current Licensee in
2022, and the license then changed under 10A
NCAC 27G .5600C Supervised Living for Adults
with Developmental Disability (6600C).

-She was not aware of why the licensed changed
and that "North Carolina Outreach (Licensee)
handled updating the license information for the
facility."

-"Never heard of not being able to live at my
home with them (clients)."

Interview on 11/5/24 with Client #3 revealed:
-No one other than AFL Provider #1 worked with
the clients in the facility.

-"That's mama bear's (AFL Provider #1) house,
she lives here with us."

Interview on 11/6/24 with the Qualified
Professional (QP) revealed:

-The Chief Quality Officer was responsible for
renewing the facility license annually.

-He was not sure how the facility license switched
from a 5600F to 5600C.

-"That's her (AFL Provider #1) home, she's been

Division of Health Service Regulation

STATE FORM

6808 YEY611

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL012-154 11/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 MEADOW VIEW STREET
MEADOW VIEW HOME
MORGANTON, NC 28655
(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 289] Continued From page 2 V 289

If continuation sheet 3 of 4

PRINTED: 11/07/2024

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL012-154 11/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 MEADOW VIEW STREET
MEADOW VIEW HOME
MORGANTON, NC 28655
(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 289] Continued From page 3 V 289

doing it (providing services) for a while."

Interview on 11/6/24 with the Chief Quality Officer
revealed:

-He was responsible for renewing the facility
license annually and updating the facility licensure
information starting in 2023.

-He renewed the facility license in 2023 as a
5600C by renewing "what was already in
Enterprise (license information system)."

-He was not sure who would have switched the
license from a 5600F to a 5600C in 2022,
"...would have been previous staff who no longer
work here."

-He will complete the annual facility license
renewal for 2025 to a 5600F, “we'll get it taken
care of."

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 4 of 4


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 03/24/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL012-154 B. WING 03/24/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 MEADOW VIEW STREET
MEADOW VIEW HOME
MORGANTON, NC 28655
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000

An annual survey was completed on 3/24/23. No
deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living for Individuals of all Disability
Groups/Alternative Family Living.

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

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

STATE FORM 6899 Q5UL11 If continuation sheet 1 of 1


facility_name: Lake James Alternative Family Living

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 05/07/2026

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
MHLO012-159 B. WING 05/07/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on 5/7/26. No
deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living for Alternative Family Living

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

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

STATE FORM 6899 KWBN11 If continuation sheet 1 of 1