summary: Statement of Deficiency - MHLCS Annual

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

PRINTED: 07/02/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

06/23/2021
STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

ID PROVIDER'S PLAN OF CORRECTION (x8)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

W 189 | STAFF TRAINING PROGRAM
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure staff were
sufficiently trained relative to personal possession
access for 1 of 3 sampled clients (client #3). The
finding is:

Observation in the group home on 6/23/21 at 8:10
AM revealed client #3 to ask staff A for his
hairbrush after his shower. Continued observation
revealed client #3 to wait for an available staff to
retrieve his hairbrush from the medication room
as the medication closet was occupied with staff
B and another client for medication
administration. Subsequent observation revealed
staff A to knock on the door of the medication
room and request the hairbrush from staff B for
the client.

Review of records for client #3 indicated an
individual support plan (ISP) dated 7/6/20.
Continued review of client #3's ISP revealed
training objectives relative to: safe eating,
brushing teeth, handwashing, and to return
belongings to his room when prompted. A review
of client #3's behavior support plan (BSP) dated
9/11/20 revealed target behaviors of inappropriate
sexual stimulation, lying, stealing, invading
privacy, noncompliance, verbal/physical
aggression, AWOL, property destruction,
self-injurious behavior, PICA, inappropriate

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

W 189

TITLE (X6) DATE

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

program participation.

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

Event ID:TZGI11

Facility ID: 955478 If continuation sheet Page 1 of 4

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(x4) ID
PREFIX
TAG

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

ID
PREFIX
TAG

PRINTED: 07/02/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/23/2021
STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

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

(8)
COMPLETION
DATE

W 189

Continued From page 1

touching, and tantrums. Subsequent review of
client #3's BSP revealed with no interventions
relative to restricting access to personal
possessions.

Interview with the clinical director on 6/23/21
verified client #3 had no restrictions relative to
access to personal possessions. Continued
interview with the clinical director verified client
#3's hairbrush should not be kept locked in the
medication room of the group home. Interview
with the facility qualified intellectual disabilities
professional (QIDP) additionally verified staff
should not be implementing any restricted access
to client #3's hairbrush or any other personal
property.

SPACE AND EQUIPMENT

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

W 436

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

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

Observation in the group home throughout the
6/22-23/21 survey revealed client #2 to participate
in various activities to include:sitting outside on
the group home porch, leisure activities at the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TZGI11

W 189

W 436

Facility ID: 955478

If continuation sheet Page 2 of 4

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

PRINTED: 07/02/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/23/2021

dining table, setting the table for the dinner meal,
meal participation, household chores and
medication administration. Continued
observations throughout the 6/22-23/21 survey
revealed client #2 to participate in activities
without the use of eyeglasses. Subsequent
observation throughout survey observations
revealed no prompts or direction from staff for
client #2 to wear eyeglasses.

Review of records for client #2 on 6/22/21
revealed an individual support plan (ISP) dated
1/19/21 with training objectives relative to use of a
schedule, increasing temporal processing,
chores, leisure activity planning, oral hygiene, rate
of eating and completing a daily routine.
Continued review of records for client #2 on
6/23/21 revealed a training objective for wearing
eyeglasses implemented 6/22/21. Review of the
6/22/21 eyeglass objective revealed the objective
to indicate client #2 will wear his eyeglasses with
a verbal prompt for 20 minutes in 90% of trials for
3 consecutive months.

Subsequent review of records for client #2
revealed a behavior support plan dated 2/15/21
for target behaviors of failure to cooperate, theft,
inappropriate touch/sexual behavior,
inappropriate verbal behavior, physical
aggression, property misuse/destruction.
Additional review of records for client #2 revealed
a vision consult dated 6/3/20. Review of the
current vision consult revealed the consult to note
a slight change in prescription with the need for
follow-up in one year.

Interview with client #2 on 6/23/21 revealed his
glasses were broken and he did not like to wear
them. Interview with the facility clinical director

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TZGI11

Facility ID: 955478

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 436 | Continued From page 2 W 436

If continuation sheet Page 3 of 4

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

PRINTED: 07/02/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

PROVIDER'S PLAN OF CORRECTION

06/23/2021

(x5)

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

revealed client #2 has eyeglasses on order and
has a history of improper care of his eyeglasses.
Interview with the facility qualified intellectual
disabilities professional (QIDP) and clinical
director verified client #2 would benefit from
training to address proper care of his eyeglasses
to address a history of improper care.

Event ID:TZGI11

Facility ID: 955478

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 436 | Continued From page 3 W 436

If continuation sheet Page 4 of 4


state: NC

facility_name: BlueWest Opportunities-Montford House

summary: Statement of Deficiency - MHLCS Follow-up

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

A. BUILDING
R-C

11/26/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET

ASHEVILLE, NC 28803

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 000} | INITIAL COMMENTS {W 000}
A revisit was conducted on 11/26/19 for all
previous deficiencies cited on 9/13/19. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

program participation.

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

Event ID:LE2U12

Facility ID: 955478

If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


raw_content:
PRINTED: 10/08/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
34G323 B. WING 10/07/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE 5 KENMORE STREET
. ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
Arevisit was conducted on 10/07/19 for all
previous deficiencies cited on 7/31/19. All
deficiencies cited during the recertification survey
have been corrected, and no new noncompliance
was found.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX12 Facility ID: 955478 If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Complaint

raw_content:
PRINTED: 09/19/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
“ CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
| STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
| AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BULDING COMPLETED
| c
| 346323 BeWING 09/13/2019
i NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
| 5 KENMORE STREET

T
| BLUEWEST OPPORTUNITIES-MONTFORD HOUSE ASHEVILLE, NC 28803
r exay iD SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

W 000 INITIAL COMMENTS W 000

COMPLAINT INTAKE #S NC154876 AND
NC155588

W154. STAFF TREATMENT OF CLIENTS W 154
CFR(s): 483.420(d)(3)

The facility must have evidence that ali alleged
violations are thoroughly investigated.

This STANDARD is not met as evidenced by:
Based on document/record review and staff
interview, the facility failed to assure 1 of 1
incident reviewed with the potential for neglect

and/or abuse, was investigated thoroughly. The
| finding is: RECEIVED

Review of the facility's internal electronic incident

logging system on 9/13/19 revealed an incident

which occurred on 8/10/19 in the afternoon. OCT - 7 2019
Further review of the report revealed an incident
involving client #1 and client #5. Continued
review of the report revealed client #5 was BI DHSR NHL& (e-
observed entering client #1's bedroom while he lack Mountain 7 WRO
was in the room. Client #5 was observed

entering the bedroom, as staff (B) witnessing the

incident, thought the client was entering a

bathroom on that hail, and not the client's room,

Client #5 was observed leaving client #1's room

with redirection by staff B. Staff B then reported

the incident immediately to managerial staff.

Interview with staff B on 9/13/19 revealed the
incident to be described as above and indicated
client #5 was in client #1's room for no more than
2 minutes. Staff B indicated that both client's
were fully clothed when observed after client #5
left the bedroom. Interview with the facility's

|
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE, THLE (X6) DATE.

Kiwi a Verek. brvsae, Peygran Adminis trate 4. 30-19
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient pratection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
foliowing the date of survey whether or not a pian of correction is provided. For nursing homes, the above findings and pians of correction are disclosable 14
days following the date these documents are made available to the facility, If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99} Previous Versions Obsolete Event ID: LE2/11 Facility 1D: 955478 If continuation sheet Page 1 of 6

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

PRINTED: 10/15/2019
FORM APPROVED
OMB NO. 0938-0391

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

34G323

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X3) DATE SURVEY
COMPLETED

c
09/13/2019

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

SUMMARY STATEMENT OF DEFICIENCIES

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

TAG

ID PROVIDER'S PLAN OF CORRECTION (x8)
COMPLETION

W 154 | Continued From page 1
program director and the qualified intellectual
disabilities professional (QIDP) revealed that staff

| members working at the time were interviewed

| about the incident on 8/10/19 and 8/11/19. The

| program director also indicated client #1 was |

| interviewed on 8/11/19 at which time he gestured

| to his genitals when asked about client #5 |

entering his room. It should be noted these two
client's have a history of possible possible

| physical/sexual interaction while residing a a
different facility. Further interview with the

| program director and QIDP revealed nursing staff

_ assessed both clients on 8/11/19 with no

| significant findings. Continued interview with the
program director revealed a formal investigation
had not been initiated for this incident and the
program director indicated a formal investigation
should have been completed based on the nature
of the incident and the possibility for neglect

and/or abuse.

W 289 MGMT OF INAPPROPRIATE CLIENT

| BEHAVIOR
| CFR(s): 483.450(b)(4) |

The use of systematic interventions to manage
inappropriate client behavior must be
| incorporated into the client's individual program |
| plan, in accordance with §483.440(c)(4) and (5) of
| this subpart. |

This STANDARD is not met as evidenced by:

_ Based on observations, record review and staff

_ interview, the facility failed to ensure interventions

| used to manage inappropriate client behaviors
were incorporated into the individual service plans |

(ISP's) for 2 of 2 sampled clients (#1 and #5).

PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 154)
|
|
|
|
W 289)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LE2J11

Facility ID: 955478 If continuation sheet Page 2 of 6

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

PRINTED: 10/15/2019
FORM APPROVED
OMB NO. 0938-0391

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

34G323

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY.

A. BUILDING COMPLETED
c
— 09/13/2019 _|

iz NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION (x5)

ID

The findings are:

A. The facility failed to update client #1's
| behavior support plan (BSP) with interventions
| which had been implemented to prevent
inappropriate behaviors. For example: |

Observations in the facility on 9/13/19 at 8:20 AM

_ revealed colored tape at the threshold of the
"men's" hallway and the "women's" hallway.
Further observations revealed door chimes which
were activated when the bedroom doors for client |
#1 and client #5 were opened. Interview with
direct care staff A and B on 9/13/19 revealed the
colored tape had been placed at the threshold of
the "men's" hallway to prompt client #5 to not go
down the hallway without being accompanied by
staff, and the colored tape at the threshold of the
“women's” hallway to prompt client #1 to not go
down the hallway. Further interview with staff A

| and B revealed the chimes had been added to

| the doors of client's #1 and #5 approximately two

weeks prior to the survey. The staff members
indicated they had not been formally trained on

| the use of the door chimes or the colored tape,

| though they did know the restrictions were added

_ to assist with better supervision of client #1 and

HO:

Review of the record for client #1 revealed an ISP
dated 5/6/19 which contained a behavior support
plan (BSP) dated 6/24/18. Review of the BSP
revealed interaction techniques for target
behaviors, which included monitoring the client
closely when with peers to ensure appropriate
personal space and refraining from inappropriate
touch. Further review did not reveal evidence of

_ documentation of using colored tape as a barrier,
or door chimes as restrictive behavioral

(X4) ID
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) |
T
W 289 Continued From page 2 W 289°

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: LE2J11

Facility ID: 965478 If continuation sheet Page 3 of 6

PRINTED: 10/15/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
34G323 B.WING 09/13/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE =, ~— DATE
| DEFICIENCY)
W 289 Continued From page 3 W289,

| interventions. Review of facility electronic | |
documents also revealed an e-mail sent to all
| facility staff on 8/11/19 related to the "supervision
protocol" at the group home, which included |
directions to not leave client #1 un-supervised
when in the common areas of the home and not |
allowing client #5 to use the bathroom on the |
is men's" hallway unless accompanied by staff.
Interview with the qualified intellectual disabilities
professional (QIDP) and the program director on
9/13/19 revealed the colored tape had been
added to the threshold of the "women's" hallway
to prompt client #1 from not going down that | | |
hallway. The QIDP indicated this colored tape |
| was added when the client moved into the home |
on 7/13/19. The QIDP indicated the door chime
was added to client #1's bedroom door on 9/11/18)
| so staff members would have increased |
awareness if client #1 left his room or if someone |
entered his room. The QIDP confirmed the | | |
colored tape and the door chime had not been | | |
| added to the client's BSP and confirmed no staff
_ had been formally trained on the use of the
restrictive interventions until 8/29/19 when some |
staff were trained on client #1's "supervision |
guidelines" and client #5's "safety rules".

B. The The facility failed to update client #5's
_ behavior support plan (BSP) with interventions |
which had been implemented to prevent | |
inappropriate behaviors. For example: |

Observations on 9/13/19 at 8:20 AM revealed | |

colored tape at the threshold of the "men's" | |

hallway and the "women's" hallway. Further |

observations revealed door chimes which were |

activated when the bedroom doors for client #1 |
|

| and client #5 were opened. Interview with direct | |
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LE2J11 Facility ID: 955478 If continuation sheet Page 4 of 6

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

PRINTED: 10/15/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
c
346323 Be WING 09/13/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE
ASHEVILLE, NC 28803
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES, ID | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE, OATE
| | DEFICIENCY)
|
W 289

W 289 | Continued From page 4
care staff A and B on 9/13/19 revealed the
| colored tape had been placed at the threshold of
the "men's" hallway to prompt client #5 to not go
down the hallway without being accompanied by |
| staff, and the colored tape at the threshold of the
"women's" hallway to prompt client #1 to not go
down the hallway. Further interview with staff A
and B revealed the chimes had been added to
the doors of client's #1 and #5 approximately two
weeks prior to the survey. The staff members
_ indicated they had not been formally trained on
the use of the door chimes or the colored tape,
though they did know the restrictions were added |
to assist with better supervision of client #1 and
#5.

Review of the record for client #5 revealed an ISP

dated 6/28/19 which included a BSP dated |

4/19/19. Review of the BSP revealed restrictive
interventions for target behaviors, which did not
include the use of colored tape or a bedroom

| door chime. Review of facility electronic

_ documents also revealed an e-mail sent to all
facility staff on 8/11/19 related to the "supervision

| protocol" at the group home, which included

directions to not leave client #1 un-supervised |
when in the common areas of the home and not
allowing client #5 to use the bathroom on the

| "men's" hallway unless accompanied by staff,
which was not included in the BSP.

_ Interview with the QIDP and the program director
on 9/13/19 revealed colored tape had been added |
| to the threshold on the "men's" hallway on 8/11/19 |
| due to an incident which occurred on 8/10/19. |
The QIDP indicated the colored tape was added
to prompt client #5 to not go down the "men's" |
hallway without supervision from staff. The QIDP |
indicated the door chime was added to the

1 t

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

Event 1D: LE2J11

Facility ID: 955478 If continuation sheet Page 5 of 6

PRINTED: 10/15/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
346323 BS VIN pe 09/13/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE 5 KENMORE STREET
‘ ASHEVILLE, NC 28803
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE
DEFICIENCY)
+ —___|
W 289 Continued From page 5 W289,

bedroom door for client #5 on 9/11/19 due to an |
| incident which occurred on 8/10/19, so staff |
would have increased awareness if client #5 left
her room or if someone entered the client's room. |
The QIDP confirmed the colored tape and the
door chime had not been added to the client's | |
BSP and confirmed no staff had been formally
trained on the use of the restrictive interventions |
| until 8/29/19 when some staff were trained on | |
client #1's “supervision guidelines" and client #5's
"safety rules" |

FORM CMS-2567(02-99) Previous Versions Obsolete Event 1D: LE2J11 Facility ID: 955478 If continuation sheet Page 6 of 6

RECEIVED

Plan of Correction for Complaint Survey 9/13/19 OCT - 7 2019
DHSR NHL&C
W 154 Staff Treatment of Clients Black Mouniain / WRO

The facility must have evidence that all alleged violations are thoroughly investigated.

The facility failed to assure an incident reviewed with the potential for neglect and/or abuse was
investigated thoroughly.

The Chief Operations Officer will provide formal training to facility staff responsible for initiating and
conducting investigations of possible abuse, neglect or exploitation of clients. The training will include
review of the facility’s protocols for reporting, investigating, documenting and notifying pertinent
parties of incidents of alleged or possible abuse/neglect/exploitation.

Training will recur at regular intervals, at least annually, in order to ensure continued
compliance with the expectation that the facility must have evidence that all alleged violations
are thoroughly investigated.

Responsible Persons: Chief Operations Officer
Mechanism to ensure compliance: Recurring training

Frequency of Mechanism: At least annually with each facility staff member responsible for
investigating alleged violations.

W 289 Management of Inappropriate Client Behavior

The use of systematic interventions to manage inappropriate client behavior must be incorporated into
the client’s individual program plan.

The facility failed to ensure interventions used to manage inappropriate client behaviors were
incorporated into the individual service plans for 2 clients. The facility failed to update 2 clients’ behavior
support plans with interventions which had been implemented to prevent inappropriate behaviors.

The Program Administrator will conduct formal training with facility staff responsible for coordinating
individual support plans (QIDPs). The training will include review of the facility’s protocols for use of an
interdisciplinary team process in planning and implementing changes in support. The training will also
include review of the faciiity’s protocol for due process for client rights restrictions.

The interventions noted during the survey will be discussed by the interdisciplinary team, and included
into the plans of the 2 clients involved, with the support of documented interdisciplinary team
consensus, to include the documented consent of the guardians and Human Rights Committee.

Regular assessments in the group home and chart reviews, and any follow-up thereby
identified, will be conducted by the Program Administrator, in order to ensure continued

compliance with the expectation that the use of systematic interventions to manage
inappropriate client behavior must be incorporated into the client’s individual program plan.

Responsible Person: Program Administrator
Mechanism to ensure compliance: Assessments and review of records

Frequency of Mechanism: At feast quarterly

inspection_type: MHLCS Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 09/19/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
c
346323 B. WING 09/13/2019

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

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE ASHEVILLE, NC 28803

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

COMPLAINT INTAKE #'S NC154876 AND
NC155588

W 154] STAFF TREATMENT OF CLIENTS W 154
CFR(s): 483.420(d)(3)

The facility must have evidence that all alleged
violations are thoroughly investigated.

This STANDARD is not met as evidenced by:
Based on document/record review and staff
interview, the facility failed to assure 1 of 1
incident reviewed with the potential for neglect
and/or abuse, was investigated thoroughly. The
finding is:

Review of the facility's internal electronic incident
logging system on 9/13/19 revealed an incident
which occurred on 8/10/19 in the afternoon.
Further review of the report revealed an incident
involving client #1 and client #5. Continued
review of the report revealed client #5 was
observed entering client #1's bedroom while he
was in the room. Client #5 was observed
entering the bedroom, as staff (B) witnessing the
incident, thought the client was entering a
bathroom on that hall, and not the client's room.
Client #5 was observed leaving client #1's room
with redirection by staff B. Staff B then reported
the incident immediately to managerial staff.

Interview with staff B on 9/13/19 revealed the
incident to be described as above and indicated
client #5 was in client #1's room for no more than
2 minutes. Staff B indicated that both client's
were fully clothed when observed after client #5
left the bedroom. Interview with the facility's

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11 Facility ID: 955478 If continuation sheet Page 1 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

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

34G323 B. WING

5 KENMORE STREET

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

STREET ADDRESS, CITY, STATE, ZIP CODE

ASHEVILLE, NC 28803

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

Cc
09/13/2019

W 154 | Continued From page 1

program director and the qualified intellectual
disabilities professional (QIDP) revealed that staff
members working at the time were interviewed
about the incident on 8/10/19 and 8/11/19. The
program director also indicated client #1 was
interviewed on 8/11/19 at which time he gestured
to his genitals when asked about client #5
entering his room. It should be noted these two
client's have a history of possible possible
physical/sexual interaction while residing a a
different facility. Further interview with the
program director and QIDP revealed nursing staff
assessed both clients on 8/11/19 with no
significant findings. Continued interview with the
program director revealed a formal investigation
had not been initiated for this incident and the
program director indicated a formal investigation
should have been completed based on the nature
of the incident and the possibility for neglect
and/or abuse.

W 289 | MGMT OF INAPPROPRIATE CLIENT
BEHAVIOR

CFR(s): 483.450(b)(4)

The use of systematic interventions to manage
inappropriate client behavior must be
incorporated into the client's individual program
plan, in accordance with §483.440(c)(4) and (5) of
this subpart.

This STANDARD is not met as evidenced by:
Based on observations, record review and staff
interview, the facility failed to ensure interventions
used to manage inappropriate client behaviors
were incorporated into the individual service plans
(ISP's) for 2 of 2 sampled clients (#1 and #5).

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11

W 154

W 289

Facility ID: 955478

If continuation sheet Page 2 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

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

STREET ADDRESS, CITY, STATE, ZIP CODE

ASHEVILLE, NC 28803

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391
(x3) DATE SURVEY
COMPLETED
Cc

09/13/2019

W 289 | Continued From page 2
The findings are:

A. The facility failed to update client #1's
behavior support plan (BSP) with interventions
which had been implemented to prevent
inappropriate behaviors. For example:

Observations in the facility on 9/13/19 at 8:20 AM
revealed colored tape at the threshold of the
"men's" hallway and the "women's" hallway.
Further observations revealed door chimes which
were activated when the bedroom doors for client
#1 and client #5 were opened. Interview with
direct care staff A and B on 9/13/19 revealed the
colored tape had been placed at the threshold of
the "men's" hallway to prompt client #5 to not go
down the hallway without being accompanied by
staff, and the colored tape at the threshold of the
"women's" hallway to prompt client #1 to not go
down the hallway. Further interview with staff A
and B revealed the chimes had been added to
the doors of client's #1 and #5 approximately two
weeks prior to the survey. The staff members
indicated they had not been formally trained on
the use of the door chimes or the colored tape,
though they did know the restrictions were added
to assist with better supervision of client #1 and
#5.

Review of the record for client #1 revealed an ISP
dated 5/6/19 which contained a behavior support
plan (BSP) dated 6/24/18. Review of the BSP
revealed interaction techniques for target
behaviors, which included monitoring the client
closely when with peers to ensure appropriate
personal space and refraining from inappropriate
touch. Further review did not reveal evidence of
documentation of using colored tape as a barrier,
or door chimes as restrictive behavioral

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11

W 289

Facility ID: 955478

If continuation sheet Page 3 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

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

STREET ADDRESS, CITY, STATE, ZIP CODE

ASHEVILLE, NC 28803

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

Cc
09/13/2019

W 289 | Continued From page 3

interventions. Review of facility electronic
documents also revealed an e-mail sent to all
facility staff on 8/11/19 related to the "supervision
protocol" at the group home, which included
directions to not leave client #1 un-supervised
when in the common areas of the home and not
allowing client #5 to use the bathroom on the
"men's" hallway unless accompanied by staff.

Interview with the qualified intellectual disabilities
professional (QIDP) and the program director on
9/13/19 revealed the colored tape had been
added to the threshold of the "women's" hallway
to prompt client #1 from not going down that
hallway. The QIDP indicated this colored tape
was added when the client moved into the home
on 7/13/19. The QIDP indicated the door chime
was added to client #1's bedroom door on 9/11/19
so staff members would have increased
awareness if client #1 left his room or if someone
entered his room. The QIDP confirmed the
colored tape and the door chime had not been
added to the client's BSP and confirmed no staff
had been formally trained on the use of the
restrictive interventions until 8/29/19 when some
staff were trained on client #1's "supervision
guidelines" and client #5's "safety rules".

B. The The facility failed to update client #5's
behavior support plan (BSP) with interventions
which had been implemented to prevent
inappropriate behaviors. For example:

Observations on 9/13/19 at 8:20 AM revealed
colored tape at the threshold of the "men's"
hallway and the "women's" hallway. Further
observations revealed door chimes which were
activated when the bedroom doors for client #1
and client #5 were opened. Interview with direct

W 289

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11

Facility ID: 955478

If continuation sheet Page 4 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

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

STREET ADDRESS, CITY, STATE, ZIP CODE

ASHEVILLE, NC 28803

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

Cc
09/13/2019

W 289 | Continued From page 4

care staff A and B on 9/13/19 revealed the
colored tape had been placed at the threshold of
the "men's" hallway to prompt client #5 to not go
down the hallway without being accompanied by
staff, and the colored tape at the threshold of the
"women's" hallway to prompt client #1 to not go
down the hallway. Further interview with staff A
and B revealed the chimes had been added to
the doors of client's #1 and #5 approximately two
weeks prior to the survey. The staff members
indicated they had not been formally trained on
the use of the door chimes or the colored tape,
though they did know the restrictions were added
to assist with better supervision of client #1 and
#5.

Review of the record for client #5 revealed an ISP
dated 6/28/19 which included a BSP dated
4/19/19. Review of the BSP revealed restrictive
interventions for target behaviors, which did not
include the use of colored tape or a bedroom
door chime. Review of facility electronic
documents also revealed an e-mail sent to all
facility staff on 8/11/19 related to the "supervision
protocol" at the group home, which included
directions to not leave client #1 un-supervised
when in the common areas of the home and not
allowing client #5 to use the bathroom on the
"men's" hallway unless accompanied by staff,
which was not included in the BSP.

Interview with the QIDP and the program director
on 9/13/19 revealed colored tape had been added
to the threshold on the "men's" hallway on 8/11/19
due to an incident which occurred on 8/10/19.
The QIDP indicated the colored tape was added
to prompt client #5 to not go down the "men's"
hallway without supervision from staff. The QIDP
indicated the door chime was added to the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11

W 289

Facility ID: 955478

If continuation sheet Page 5 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER: A

34G323 B.

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

BUILDING

WING

5 KENMORE STREET

ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/19/2019
FORM APPROVED
OMB NO. 0938-0391
(x3) DATE SURVEY
COMPLETED
Cc

09/13/2019

bedroom door for client #5 on 9/11/19 due to an
incident which occurred on 8/10/19, so staff
would have increased awareness if client #5 left
her room or if someone entered the client's room.
The QIDP confirmed the colored tape and the
door chime had not been added to the client's
BSP and confirmed no staff had been formally
trained on the use of the restrictive interventions
until 8/29/19 when some staff were trained on
client #1's "supervision guidelines" and client #5's
"safety rules".

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LE2J11

Facility ID: 955478

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 289 | Continued From page 5 W 289

If continuation sheet Page 6 of 6


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 08/05/201
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APEROVED

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

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

34G323 ——————————ne 07/31/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE ASHEVILLE, NC 28803

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY) |

W 189| STAFF TRAINING PROGRAM W 189)
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:

Based on observations, record review and aan See atte hed Dorm alo| 5
interview, the facility failed to assure staff were

effectively trained with regard to behavior |
management for 1 of 4 sampled clients (#3) and
protecting client health with handwashing for 2 of
4 sampled clients (#1 and #3). The findings are:

A. The facility failed to ensure support for client
#3 relative to behavior management. For | | |

example: RECEIVED

Observation on 7/31/19 at 6:55 AM revealed staff
D and client #3 to walk to the medication room of
the group home. Further observation revealed
client #3 to take a cup of water to the medication
room and staff D to carry a personal beverage
container into the medication room. Observation
at 7:05 AM revealed loud noises to come from
the medication room while staff E went to the
medication room, knocked on the door with no
response from staff, used a key to open the door |
and assisted client #3 with exiting the medication
room holding staff D's personal beverage j j
container, Staff D was observed ta look
disheveled with glasses crooked and hair in
disarray while staff D stood in the group home
hallway.

AUG 1 2 20g

DHSRNHL&C
Black Mountain /WRO

Review of records for client #3 on 7/31/19
revealed an individual support plan (ISP) dated

LABORATORY Te OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE

(X6) DATE

aA
Any deficiency statem:
other safeguards provide suficignt protection to the patients. (See instructions) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whéther or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:KMWX11 Facility ID: 955478 If continuation sheet Page 1 of 5

PRINTED: 0 1201
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM ApeROVED

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

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

34G323 B. WING = | 07/31/2019
STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
PROVIDER'S PLAN OF CORRECTION | og
(EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
CROSS-REFERENCED TOTHEAPPROPRIATE | DATE
DEFICIENCY) i

NAME OF PROVIDER OR SUPPLIER:

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

W 189 | Continued From page 1 W 189
9/12/18. Further review of the ISP revealed a |
behavior support plan dated 9/22/16 with target
behaviors of aggression, property destruction and
agitation. Continued review of the ISP revealed

the plan to state common triggers for behaviors of |
client #3 have inciuded: obsessiveness about |

drinks and attempts with success at times to steal |
drinks. The ISP further revealed client #3 will |
drink any unattended drinks he can find. He will
attempt to drink coffee straight out of the coffee
pot and drinks out of the faucet when he goes

into the bathroom. |

Interview with staff D on 7/31/19 verified client #3 | — i | -
had physically aggressed her as the client | See ctloched om 91.20] i9
attempted to get her beverage container. Further |

interview with staff D revealed client #3 obsesses
over drinks and staff is unable to leave personal
drinks around the client or he steals them.
Additional interview with staff D revealed she had
coffee in the personal beverage container and |
client #3 particularly likes coffee. Interview with
administration staff verified client #3 obsesses
over drinks and staff D should not have had a
beverage container with client #3 in the
medication room as this is an identified trigger for
the client. |

B. The facility failed to ensure proper client
hygiene relative to handwashing for client #1. For |
example: |
Observation on 7/31/18 at 6:22 AM revealed
client #1 to enter the medication room with staff D
for his morning medications. Client #1 was
observed to sitin a chair and assist with the
morning medication pass without washing his
hands or verbal prompts by staff to use sanitizer.
Further observation during the medication pass

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11 Facility ID: 955478 If continuation sheet Page 2 of 5

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

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

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

346323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(4) ID
PREFIX
TAG

W 189 | Continued From page 2

revealed staff to place multiple medication
cassettes in client #1's hand and for the client to
take off the correct plastic tab for each
medication and place the tab into the trash can
beside the client. Client #1 was observed to
touch the top of the trash can with each tab
place: ‘oO the trash can. Subsequent
observation revealed no hand sanitizer or
handwashing occurred after client #1 touched the
trash can and continued participation in the
medication administration process.

Interview with staff D on 7/31/19 verified client #1
should have been prompted to wash his hands
before the medication pass began and she failed
to prompt the ciient to do so as she was nervous.
Further interview with staff D verified she should
have prompted the client to use sanitizer each
time he touched the trash can during the
medication administration process or allowed the
client to put all tabs in a pile to be thrown away at
the end of the med pass. Interview with |
administration staff verified handwashing should
have occurred with client #1's medication pass —|
and with each time the client touched the trash
can.

C. The facility failed to ensure proper client
hygiene relative to handwashing for client #3. For
example:

| Observation on 7/30/19 at 5:15 PM revealed
client #3 to exit the activity roor the group
home from riding an exercise bike and to be
verbally prompted by staff Ato "check schedule".
Further observation revealed client #3 to check
an activity schedule and walk to the kitchen to
access dishes to set the table for the dinner meal
with plates, cups and utensils for all clients

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING. |

(X3) DATE SURVEY
COMPLETED

07/31/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
PROVIDER'S PLAN OF CORRECTION 0%)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

PREFIX
TAG

W 189 |

Bee attached Porm

ious Versions Obsolete Evont ID:KMWX11

FORM CMS-2567(02-09) Pr

Facility ID: 955478 \f continuation sheet Page 3 of 5

Pp
DEPARTMENT OF HEALTH AND HUMAN SERVICES ge ACROVED

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

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED

346323 BA WING ee 07/31/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (x6)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION

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

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

without washing his hands. Subsequent |
observation revealed staff A to monitor client #3 |
while setting the table.

Interview with administration staff and the facility |
qualified intellectual disabilities professional on |
7/21/19 verified client #2 should have washed his |
hands before setting the table for the dinner meal. | |
W 382 | DRUG STORAGE AND RECORDKEEPING W 382}
CFR(s): 483.460(I)(2)

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

administration. Ree ottached Carm a|goli9

W 189 | Continued From page 3 W 189

This STANDARD is not met as evidenced by: |
Based on observation, interview and record
review, the facility failed to assure medications for
1 of 3 sampled clients (#4) were kept locked
except when being prepared for administration. |
The finding is: |

Observations in the group home on 7/30/19 at
4:56 PM revealed staff member Ato access a
storage container containing topicals and | |
treatments for client #4. Further observations | |
revealed staff Ato take the storage container to |
client #4's room and leave it in the room

| unsupervised with client #4 while the client was
preparing to take a shower. Continued

observations at 5:00 PM revealed staff A to | |

and staff A returned to the client's room.
Interview with staff A on 7/30/19 confirmed the

re-enter the bedroom to assist client #4 to the | \
bathroom to take a shower, leaving the storage
container in the bedroom unattended until |
approximately 5:15 PM. At that time, client #4 |

FORM CMS-2567(02-29) Previous Versions Obsolete Event (1D: KMWX11 Facility ID: 055478 If continuation sheet Page 4 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

W 382 | Continued From page 4

storage container contained prescribed topicals
and treatments. Staff A stated she had assisted
with the application of Vick's vapor rub ointment
and petroleum jelly to the client's feet and toes
after the shower. Observations of the items in

j the storage container included Vick's ointment,
petroleum jelly, triamcinolone 5% cream, Eucerin

cream, and Debrox 6.5% eardrops.

Review of client #4’s record on 7/31/19 revealed
current physician's orders confirming the
prescription of the topicals and treatments
observed in the storage container for client #4. |
Interview with the facility registered nurse on |
7/31/19 confirmed these topicals and treatments |
shouid not be ieft out of the medication room
unattended, and the nurse indicated the topicals
should have been administered in the medication
room after the client's shower.

FORM CMS-2567(02-99) Previous Versions Obsolete Event iD: KMWX11

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2019
STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

PROVIDER'S PLAN OF CORRECTION 8)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

W 382

|
4 |ao|q

Facility ID: 955478 if continuation sheet Page 5 of 5

Plan of Correction RECEIVED

Montford Group Home
Annual Recertification Survey
July 30 and 31, 2019 AUG 1 2 2019

DHSR NHL&C
Black Mountain / WRO
W189 Staff Training Program The facility must provide each employee with initial and continuing
training that enables the employee to perform his or her duties effectively, efficiently, and

competently.

A. DSP's will be re-irained on refraining from bringing personai food or beverages inio the group
home. Additionally, signage will be placed on the front door reminding staff that bringing
personal food and drinks is prohibited.

B. DSP's will be re-trained on the importance of handwashing and good hygiene prior to and
during medication administration. DSP’s will be reminded that anyone involved in passing
medications, both staff and residents must wash their hands prior to passing or taking
medications. Additionally, staff will be reminded that if they or the residents touch the
trashcan during the pass they will be required to sanitize their hands betore touching
medications.

C. DSP’s will be re-trained on the importance of handwashing prior to meal preparation and

setting the table.

Success of this re-training wili be measured during observation/coaching sessions dione by the
Program Administrator, Residential Services Director, QP’s, and/or the Shitt Manager's.

All re-training and observation/coaching sessions will be completed by September 20, 2019

W382-Drug Storage and Record Keeping. The facility must keep all drugs and biologicals locked
except when being prepared for administration.

All DSP’s will be re-trained in proper administration and storage practices related to topical
medications/treatments. Re-training will include ensuring that staff are aware that topical
medications/treatments must be kept locked until the actual time of administration.

Success of this re-iraining will be measured during observation and coaching sessions done by the
Program Administrator, Residential Services Director, QP's, and/or Shift Manager's.

All retraining and observation/coaching sessions will be completed by September 20, 2019

re bs | OP
FI ann Administretor “| a| iq

inspection_type: MHLCS Annual


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 08/05/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

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

(X3) DATE SURVEY
COMPLETED

B. WING

34G323 07/31/2019

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

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE ASHEVILLE, NC 28803

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

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES.

W 189 | STAFF TRAINING PROGRAM Ww 189
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observations, record review and staff
interview, the facility failed to assure staff were
effectively trained with regard to behavior
management for 1 of 4 sampled clients (#3) and
protecting client health with handwashing for 2 of
4 sampled clients (#1 and #3). The findings are:

A. The facility failed to ensure support for client
#3 relative to behavior management. For
example:

Observation on 7/31/19 at 6:55 AM revealed staff
D and client #3 to walk to the medication room of
the group home. Further observation revealed
client #3 to take a cup of water to the medication
room and staff D to carry a personal beverage
container into the medication room. Observation
at 7:05 AM revealed loud noises to come from
the medication room while staff E went to the
medication room, knocked on the door with no
response from staff, used a key to open the door
and assisted client #3 with exiting the medication
room holding staff D's personal beverage
container. Staff D was observed to look
disheveled with glasses crooked and hair in
disarray while staff D stood in the group home
hallway.

Review of records for client #3 on 7/31/19
revealed an individual support plan (ISP) dated

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11 Facility ID: 955478 If continuation sheet Page 1 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

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

ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2019

W 189 | Continued From page 1

9/12/18. Further review of the ISP revealed a
behavior support plan dated 9/22/16 with target
behaviors of aggression, property destruction and
agitation. Continued review of the ISP revealed
the plan to state common triggers for behaviors of
client #3 have included: obsessiveness about
drinks and attempts with success at times to steal
drinks. The ISP further revealed client #3 will
drink any unattended drinks he can find. He will
attempt to drink coffee straight out of the coffee
pot and drinks out of the faucet when he goes
into the bathroom.

Interview with staff D on 7/31/19 verified client #3
had physically aggressed her as the client
attempted to get her beverage container. Further
interview with staff D revealed client #3 obsesses
over drinks and staff is unable to leave personal
drinks around the client or he steals them.
Additional interview with staff D revealed she had
coffee in the personal beverage container and
client #3 particularly likes coffee. Interview with
administration staff verified client #3 obsesses
over drinks and staff D should not have had a
beverage container with client #3 in the
medication room as this is an identified trigger for
the client.

B. The facility failed to ensure proper client
hygiene relative to handwashing for client #1. For
example:

Observation on 7/31/19 at 6:32 AM revealed
client #1 to enter the medication room with staff D
for his morning medications. Client #1 was
observed to sit in a chair and assist with the
morning medication pass without washing his
hands or verbal prompts by staff to use sanitizer.
Further observation during the medication pass

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11

W 189

Facility ID: 955478

If continuation sheet Page 2 of 5

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

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

B. WING

(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
A. BUILDING

5 KENMORE STREET

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

ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2019

W 189 | Continued From page 2

revealed staff to place multiple medication
cassettes in client #1's hand and for the client to
lake off the correct plastic tab for each
medication and place the tab into the trash can
beside the client. Client #1 was observed to
ouch the top of the trash can with each tab
placed into the trash can. Subsequent
observation revealed no hand sanitizer or
handwashing occurred after client #1 touched the
rash can and continued participation in the
medication administration process.

nterview with staff D on 7/31/19 verified client #1
should have been prompted to wash his hands
before the medication pass began and she failed
io prompt the client to do so as she was nervous.
Further interview with staff D verified she should
have prompted the client to use sanitizer each
ime he touched the trash can during the
medication administration process or allowed the
client to put all tabs in a pile to be thrown away at
he end of the med pass. Interview with
administration staff verified handwashing should
have occurred with client #1's medication pass
and with each time the client touched the trash
can.

C. The facility failed to ensure proper client
hygiene relative to handwashing for client #3. For
example:

Observation on 7/30/19 at 5:15 PM revealed
client #3 to exit the activity room in the group
home from riding an exercise bike and to be
verbally prompted by staff A to "check schedule".
Further observation revealed client #3 to check
an activity schedule and walk to the kitchen to
access dishes to set the table for the dinner meal
with plates, cups and utensils for all clients

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11

W 189

Facility ID: 955478

If continuation sheet Page 3 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

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

ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2019

W 189 | Continued From page 3

without washing his hands. Subsequent
observation revealed staff A to monitor client #3
while setting the table.

Interview with administration staff and the facility
qualified intellectual disabilities professional on
7/31/19 verified client #3 should have washed his
hands before setting the table for the dinner meal.
W 382 | DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(I)(2)

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

his STANDARD is not met as evidenced by:
Based on observation, interview and record
review, the facility failed to assure medications for
of 3 sampled clients (#4) were kept locked
except when being prepared for administration.
The finding is:

=

Observations in the group home on 7/30/19 at
4:56 PM revealed staff member A to access a
storage container containing topicals and
reatments for client #4. Further observations
revealed staff A to take the storage container to
client #4's room and leave it in the room
unsupervised with client #4 while the client was
preparing to take a shower. Continued
observations at 5:00 PM revealed staff A to
re-enter the bedroom to assist client #4 to the
bathroom to take a shower, leaving the storage
container in the bedroom unattended until
approximately 5:15 PM. At that time, client #4
and staff A returned to the client's room.
Interview with staff A on 7/30/19 confirmed the

W 189

W 382

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11

Facility ID: 955478

If continuation sheet Page 4 of 5

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

5 KENMORE STREET

ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/05/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2019

storage container contained prescribed topicals
and treatments. Staff A stated she had assisted
with the application of Vick's vapor rub ointment
and petroleum jelly to the client's feet and toes
after the shower. Observations of the items in
the storage container included Vick's ointment,
petroleum jelly, triamcinolone .5% cream, Eucerin
cream, and Debrox 6.5% eardrops.

Review of client #4's record on 7/31/19 revealed
current physician's orders confirming the
prescription of the topicals and treatments
observed in the storage container for client #4.
Interview with the facility registered nurse on
7/31/19 confirmed these topicals and treatments
should not be left out of the medication room
unattended, and the nurse indicated the topicals
should have been administered in the medication
room after the client's shower.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KMWX11

Facility ID: 955478

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 382 | Continued From page 4 W 382

If continuation sheet Page 5 of 5


raw_content:
PRINTED: 03/29/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
346323 03/21/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
WNC GROUP HOME-MONTFORD
ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000
No deficiencies were cited as a result of a
complaint survey conducted on 3/21/19 for Intake
#NC00148510.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: U5W611 Facility ID: 955478 If continuation sheet Page 1 of 1


raw_content:
PRINTED: 12/20/2018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
34G323 B. WING 12/18/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
WNC GROUP HOME-MONTFORD 5 KENMORE STREET
. ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
No deficient practices were cited during the
complaint investigation intake #NC00145102.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:09RJ11 Facility ID: 955478 If continuation sheet Page 1 of 1


raw_content:
PRINTED: 10/04/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346323 10/04/2018

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

WNC GROUP HOME-MONTFORD
ASHEVILLE, NC 28803

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

Arevisit was conducted on 10/4/18, for all
previous deficiencies cited on 8/1/18. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.

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

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MQ0012 Facility ID: 955478 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Annual

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

WNC GROUP HOME-MONTFORD

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

PRINTED: 08/02/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/01/2018
STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

W 189 | STAFF TRAINING PROGRAM
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure staff were
trained to provide supervision during cooking and
eating for 2 of 3 sampled clients (#3 and #4).
The findings are:

A. The facility failed to ensure staff provided
proper monitoring for client #3 relative to
supervision while cooking. For example:

Observation in the group home on 8/1/18 at 7:10
AM revealed staff assisted client #3 to prepare
his breakfast which included a fried egg, grits,
applesauce and beverages. Continued
observation revealed staff assisted client #3 to
turn on the gas burner, place margarine and an
egg in a pan and place it on the burner. Staff was
then observed to leave the kitchen to assist
another client while client #3 was standing alone
in the kitchen in front of the stove.

Review of the record for client #3 on 7/31/18 and
8/1/18 revealed an Individual Program Plan (IPP)
dated 9/10/17 which revealed client #3 to have a
diagnosis of autism and moderate intellectual
disability. Further review of the IPP revealed a
comprehensive functional assessment (CFA)
dated 3/6/18. Review of the CFA revealed client
#3 needs physical assistance relative to safety
and harm prevention.

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

W 189

TITLE (X6) DATE

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

program participation.

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

Event ID:MQ0011

Facility ID: 955478 If continuation sheet Page 1 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

WNC GROUP HOME-MONTFORD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

5 KENMORE STREET
ASHEVILLE, NC 28803

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/02/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/01/2018

Interview with the qualified intellectual disabilities
professional (QIDP) conducted on 8/1/18
revealed at no time should a client be left
unattended in the kitchen with the stove on.
Further interview verified client #3 needs physical
assistance with cooking skills and staff should
have been present with the client at all times
while the client was cooking his breakfast.

B. The facility failed to ensure staff provided
proper monitoring relative to dining supervision
for client #4. For example:

Observations in the group home on 8/1/ 18 at
7:28 AM revealed client #4 to prepare her
breakfast meal in the kitchen with staff
assistance. Continued observation revealed
client #4 to sit at the kitchen table and eat
independently while staff at various times left the
client unmonitored while assisting another client.

Review of record for client #4 on 7/31/18 and
8/1/18 revealed an IPP dated 7/23/18. Review of
client #4's IPP revealed dining guidelines for all
meals and snacks dated 6/27/17. Review of the
guidelines revealed the client will follow a dining
routine to slow her rate of eating. Further review
revealed guidelines were developed because the
team felt there were issues with the client's rate
of eating. Additionally, review of the objective
revealed the client will be verbally reminded that
she is to eat slowly.

Interview with the QIDP revealed client #4 had a
choking incident within the past 5 months.
Further interview with the QIDP verified the
client's dining guidelines are still current and staff
should be present and usually sitting with client

#4 while she is eating. Interview with the program

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:MQ0011

Facility ID: 955478

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 189 | Continued From page 1 W 189

If continuation sheet Page 2 of 3

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

WNC GROUP HOME-MONTFORD

PRINTED: 08/02/2018
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/01/2018
STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

administrator further verified the client should not
be left unattended during meals.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:MQ0011

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 189 Continued From page 2 W 189

Facility ID: 955478 If continuation sheet Page 3 of 3


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 08/02/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

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

34G323 B. WING 08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE |
5 KENMORE STREET

.
WNC GROUP HOME-MONTFORD ASHEVILLE, NC 28803 |

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

STAFF TRAINING PROGRAM
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:

Based on observation, record review and
interview, the facility failed to ensure staff were
trained to provide supervision during cooking and
eating for 2 of 3 sampled clients (#3 and #4).
The findings are:

A. The facility failed to ensure staff provided
proper monitoring for client #3 relative to
supervision while cooking. For example:

Observation in the group home on 8/1/18 at 7:10
AM revealed staff assisted client #3 to prepare
his breakfast which included a fried egg, grits,
applesauce and beverages. Continued
observation revealed staff assisted client #3 to
turn on the gas burner, place margarine and an
egg in a pan and place it on the burner. Staff was
then observed to leave the kitchen to assist
another client while client #3 was standing alone
in the kitchen in front of the stove.

Review of the record for client #3 on 7/31/18 and
8/1/18 revealed an Individual Program Plan (IPP)
dated 9/10/17 which revealed client #3 to have a
diagnosis of autism and moderate intellectual
disability. Further review of the IPP revealed a
comprehensive functional assessment (CFA)
dated 3/6/18. Review of the CFA revealed client
#3 needs physical assistance relative to safety
and harm prevention.

LABORATORY DIRECTOR'S QR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE:
A v

vy

other safeguards provide sufficient prote’ e patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not @piah of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: MQO011 Facility ID: 955478 If continuation sheet Page 1 of 3

PRINTED: 08/02/2018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

346323 BOWING ____—____.____-------. 08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803"

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

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

WNC GROUP HOME-MONTFORD

Continued From page 1

Interview with the qualified intellectual disabilities
professional (QIDP) conducted on 8/1/18
revealed at no time should a client be left
unattended in the kitchen with the stove on.
Further interview verified client #3 needs physical
assistance with cooking skills and staff should
have been present with the client at all times
while the client was cooking his breakfast.

B. The facility failed to ensure staff provided
proper monitoring relative to dining supervision
for client #4. For example: ,

Observations in the group home on 8/1/ 18 at
7:28 AM revealed client #4 to prepare her
breakfast meal in the kitchen with staff
assistance. Continued observation revealed
client #4 to sit at the kitchen table and eat
independently while staff at various times left the
client unmonitored while assisting another client.

Review of record for client #4 on 7/31/18 and
8/1/18 revealed an IPP dated 7/23/18. Review of
client #4's IPP revealed dining guidelines for all
meals and snacks dated 6/27/17. Review of the
guidelines revealed the client will follow a dining
routine to slow her rate of eating. Further review
revealed guidelines were developed because the
team felt there were issues with the client's rate
of eating. Additionally, review of the objective
revealed the client will be verbally reminded that
she is to eat slowly.

Interview with the QIDP revealed client #4 had a
choking incident within the past 5 months.

Further interview with the QIDP verified the
client's dining guidelines are still current and staff
should be present and usually sitting with client
#4 while she is eating. Interview with the program

FORM CMS-2567 (02-99) Previous Versions Obsolete Event 1D: MQ0011 Facility 1D: 955478 lf continuation sheet Page 2 of 3

Crt ara “Froqrom Administrotor alelin

PRINTED: 08/02/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0938-03914

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION {IDENTIFICATION NUMBER: A. BUILDING COMPLETED

346323 B.WING 08/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

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

WNC GROUP HOME-MONTFORD

Continued From page 2
administrator further verified the client should not
be left unattended during meals.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: MQ0011 Facility ID: 955478 If continuation sheet Page 3 of 3

eae | Yen (Troqvom Adminis on al ol is

Plan of Correction
Montford House Annual Recertification Survey

July 31-Aug 1, 2018

W 189 Staff Training Program CFR(s)

(e) The facility must provide each employee with initial and continuing
training that enables the employee to perform his or her duties effectively,
efficiently, and competently.

The agency will ensure that all staff are properly trained to effectively, efficiently
and competently perform his or her job duties. The QIDP will create formal
guidelines for each resident regarding kitchen safety and rules for staff
monitoring while residents are in the kitchen/dining room area (based off a
resident's individual CFA) and train all staff accordingly.

This will be monitored by the Program Administrator, QIDP and House Manager.
Monitoring will occur at least every 6 months.

This will be completed by September 17, 2018.

Ge ° ae
Received

2,
%,
3
3
3
Sy

7
Signature Date


facility_name: Reuter Cottage

summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 03/20/2026

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
MHLO011-203 B. WING 03/19/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000

An annual and complaint survey was completed
on 3/19/26. The complaint was unsubstantiated
(# NC00235844). No deficiencies were cited.

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

This facility is licensed for 6 and currently has a
census of 3. The survey sample consisted of
audits of 2 current clients and 1 former client.

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

STATE FORM 6899 26M211 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Complaint


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

raw_content:
PRINTED: 07/16/2025

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-203 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and follow up survey was completed
on July 15, 2025. No deficiencies were cited.

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

This facility is licensed for 6 and has a current
census of 5. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up