summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-204

CUMMINGS COTTAGE

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/05/2018
FORM APPROVED

10/26/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

ASHEVILLE, NC 28806

(X3) DATE SURVEY
COMPLETED

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

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

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

Review on 10/26/18 of fire and disaster drills from
October 2017-September 2018 revealed:

-No documentation of fire drill having been
conducted during:

--1st or 2nd shifts from April 2018 through June
2018.

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed on 10/26/18. A
deficiency was cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment Facility.
V 114) 27G .0207 Emergency Plans and Supplies Vv 114

TITLE

(X6) DATE

6H8E11 If continuation sheet 1 of 2

PRINTED: 11/05/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL011-204 B. WING ____ 10/26/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

CUMMINGS COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 1 Vv 114
--3rd shift from January 2018 through March
2018.

-No documentation of disaster drill having been
conducted on:

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

Interview on 10/26/18 with the Residential
Director revealed:

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

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

Division of Health Service Regulation
STATE FORM 6899 6H8E11 If continuation sheet 2 of 2

inspection_type: MHLCS Annual


state: NC

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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 11/07/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
11/06/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(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
Arevisit was conducted on 11/6/2025 for all
previous deficiencies cited on 8/13/2025. All
deficiencies were corrected and no new
non-compliance 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:X4H012

Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES tes

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ; ‘coMeL ETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

346089 BWING
STREET ADDRESS. CITY, STATE. ZIP CODE
91 POPLAR CIRCLE

SWANNANOA, NC 28778

08/13/2025

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 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 sid

DEFICIENCY)

W130 PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure privacy during
treatment and care of personal needs.

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to ensure 1 of 5 audit clients (#2) at
Beaucatcher was afforded privacy during
personal care. The findings is:

Observations in the home on 11/13/25 at 6:27 AM
revealed client #2 standing in her bedroom
naked, trying to fasten her bra for approximately
three minutes and visible from the hallway.
Continued observation revealed staff A to enter
client #2's room to ask if she needed any
assistance. Further observation revealed client
#2 to decline assistance and staff A to exit her
room leaving the door wide open. Subsequent
observation revealed client #2 to step out of sight
from the hallway but to continue dressing with the
door wide open.

Interview on 11/13/25 with the RN/Qualified
Intellectual Disabilities Professional (RN/QIDP)

revealed staff should close the door for client #2

during personal care to ensure her privacy.

W249 PROGRAM IMPLEMENTATION W 249
CFR(s): 483.440(d)1)

RECEIVED

As soon as the interdisciplinary team has

formulated a client's individual program plan,

each client must receive a continuous active

treatment program consisting of needed

interventions and services in sufficient number DHSR-MH Licensure Sect
and frequency to support the achievement of the

objectives identified in the individual program

plan.'
LABORATORY DIRECTOR'S OR PROVIDER'SUP!

JER REPRESENTATIVE'S SIGNATURE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institufion may be excused ‘rom correcting providing it is determined that
other safeguards provide sufficient protection to the patients , (See instruc! Ins.) Except for nursing homes, the findings stated above are disciosable 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: xaHort Facility 10. 922418 If continuation sheet Page 1 of 4

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X4) 10
PREFIX
TAG

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

W 249 Continued From page 1

This STANDARD is not met as evidenced by:
Based on observations, record review and
interview, the facility failed to ensure 1 of 5 audit
clients (#5) at Hawksbill received a continuous
active treatment program consisting of neeced
interventions as identified in the person-centered
plan (PCP). The finding is:

Observations in the group home on 8/12/25
revealed client #5 to wear a gait belt and for staff
to ambulate client around the home utilizing his
gait belt. Continued observation at 4:22 PM
revealed staff to ambulate client #5 next door to
Beaucatcher utilizing their gait belt only. Further
observations at 5:15 PM revealed staff to
ambulate client #5 back to Hawksbill utilizing their
gait beit only. Additional observations in the group
home revealed a walker to be sitting in the
hallway corner.

Review of client #5's record on 8/13/25 revealed
a PCP dated 8/7/25 which indicated a habilitation
program for physical therapy exercise, to include
gait training, seated exercises, and standing
exercises. Continued review of client #5's record
revealed a physical therapy (PT) evaluation dated
7/10/25, Review of the PT evaluation indicated
client #5 is prescribed a gait belt, walker, and
wheelchair for long distances. Continued review
of the PT evaluation indicated client #5 ambulates
with a walker and gait belt with standby to
minimal assistance.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/13/25 confirmed client
#5's PCP and PT recommendations are current.

FORM CMS-2567 (02-98) Previous Versions Obsolete Event ID X4H011

PRINTED: 08/14/2025
FORM APPROVED
OMB NO, 0938-0391

(X3) DATE SURVEY
COMPLETED

(2) MULTIPLE CONSTRUCTION.
A BUILDING

_—— 08/43/2025

STREET ADDRESS. CITY. STATE. ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE.
DEFICIENCY)

Facilty ID: 922418 If continuation sheet Page 2 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES oo

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

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346089 B.WING
STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

SWANNANOA, NC 28778

08/13/2025

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

4) 1D SUMMARY STATEMENT OF DEFICIENCIES 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 249 Continued From page 2 W 249
Continued interview with the QIDP revealed client
#5 has made progress with ambulation and the
walker is not always needed while in the home.
Further interview with the QIDP revealed staff are
supposed to support client #5 with ambulation
utilizing his walker anytime he leaves the home.
W474 MEAL SERVICES W 474
CFR(s): 483.480(b)(2)(iii)

Food must be served in a form consistent with the
developmental level of the client.

This STANDARD is not met as evidenced by:
Based on observations, record review and
interview, the facility failed to ensure food was
Served in a form consistent with the
developmental level of 1 of 5 audit clients (#5) at
Hawksbill. The finding is:

Observations in the group home on 8/12/25 at
4:00 PM revealed client #5 to participate in group
snack. Continued observations revealed client #5
to choose Cheeto Puffs and for staff to serve
them cut in half. Observation of the dinner meal
at 5:34 PM revealed it to include Greek pasta,
marinated cucumbers and onions, green beans,
sliced orange and pineapple, milk and water,
Additional observation revealed client #5 to be
served the dinner meal in whole form and to
participate independently in the dinner meal.

Observations in the group home on 8/13/25 at
7:06 AM revealed the breakfast meal to include
scrambled eggs, grits, Greek yogurt, mixed
berries, milk and coffee. Continued observations
revealed client #5 to be served the breakfast
meal in whole form and to participate
independently in the breakfast meal.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: X4H011 Facility ID; 922478 if continuation sheet Page 3 of 4

PRINTED: 08/14/2025
FORM APPROVED.
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

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

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

(X2) MULTIPLE CONSTRUCTION
A BUILDING

34G089 B, WING

08/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE
91 POPLAR CIRCLE

SWANNANOA, NC 28778

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(x4) 1D. SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE oare

DEFICIENCY)

W474 Continued From page 3
Review of client #5's records on 8/13/25 revealed
a nutritional assessment dated 8/1/24 which
indicated their diet order to be regular, finely
chopped,

Interview with qualified intellectual disabilities
professional (QIDP) on 8/13/25 confirmed the diet
order for client #5 is current. Continued interview
with the QIDP verified finely chopped consistency
should be less than one quarter inch with certain
foods minimally processed in a food processor,
depending on texture. Further interview with the
QIDP confirmed staff are responsible for ensuring
clients receive their diet orders as prescribed.

FORM CMS-2567(02-99) Previous Versions Obsciete Event ID. X4H011 Facility 1D 922418 if continuation sheet Page 4 of 4

Blue West Opportunities - Swannanoa
Plan of Correction

Survey 08/12/25 - 08/13/2025

W130

The facility must ensure the rights of all clients. Therefore, the facility must ensure Privacy
during treatment and care of personal needs.

This STANDARD is not met as evidenced by: Based on observations and interview, the facility failed
to ensure 1 of 5 audit clients (#2) at Beaucatcher was afforded Privacy during personal care.

Staff will be trained on Client Rights by the QIDP and support instruction to ensure the client’s
safety and optimize support for privacy. Standard training, routine monitoring, and any follow-ups
thereby identified, will be conducted by the person responsible to ensure the client is provided
Privacy.

Responsible Person(s): QIDP, QIDP Assistant, Site Director

Mechanism to ensure compliance: Standard training, visual monitoring, Administrative Quick
View Assessments

Frequency of Mechanism: ongoing as needed, monthly as assigned.

W249

As soon as the interdisciplinary team has formulated a client’s individual program plan, each
client must receive a continuous active treatment program plan consisting of needed
interventions and services in sufficient number and frequency to support the achievement if
the objectives identified in the individual Program.

This STANDARD is not met as evidenced by: Based on observations, record review and interview,
the facility failed to ensure 1 of 5 audit clients {#5) at Hawksbill received a continuous active
treatment program consisting of needed interventions as identified in the person-centered plan
(PCP).

Motoric Specialist and PT will review the recommendations for safe ambulation and transfers of
each SW resident. Training will be offered at each group home. Weekly assessments will be
completed in each home for compliance. Any discrepancies found in the assessments will be
discussed with the appropriate staff and any follow-ups will be sent to the appropriate supervisor.

Responsible Person: QIDP, Site Director, Motoric Clinical Specialist

Mechanism to ensure compliance: Assessments and observation of transfers and ambulation,
Administrative Quick View Assessments, Transfer and Ambulation Sheet.

Frequency of mechanism: monthly, on going

W474
Food must be served ina form consistent with the developmental level of the client.

This STANDARD is not met as evidenced by: Based on observations, record review and
interview, the facility failed to ensure food was served in a form consistent with the
developmental level of 1 of 5 audit clients (#5) at Hawksbill.

The Dietary Manager/Clinical Support Specialist will conduct training with staff about the
importance of adhering to a client’s prescribed diet, nutritional needs, and where individual
dietary information is located within the group home.

Routine in-home monitoring and observations are made by the Site Director, Shift Supervisors,
Assistant QIDP and QIDP. in addition, the Dietary Manager/Clinical Support Specialist and Site
Director delegates responsibility to the Supervisors to conduct two observation-based Mealtime
Assessments each month.

Responsible Person(s): Dietary Manager/Clinical Support Specialist, Site Director, QIDP,
Supervisors; TE and MB.

Mechanism to ensure compliance: Visual monitoring, corrections as needed, Mealtime
Assessments.

Frequency of Mechanism: As often as needed on @ Case-to-case basis, two Mealtime
Assessments each month.

document_type: Plan of Correction


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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

PRINTED: 08/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION (x5)

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

W 130 | PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure privacy during
treatment and care of personal needs.

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to ensure 1 of 5 audit clients (#2) at
Beaucatcher was afforded privacy during
personal care. The findings is:

Observations in the home on 11/13/25 at 6:27 AM
revealed client #2 standing in her bedroom
naked, trying to fasten her bra for approximately
three minutes and visible from the hallway.
Continued observation revealed staff A to enter
client #2's room to ask if she needed any
assistance. Further observation revealed client
#2 to decline assistance and staff A to exit her
room leaving the door wide open. Subsequent
observation revealed client #2 to step out of sight
from the hallway but to continue dressing with the
door wide open.

Interview on 11/13/25 with the RN/Qualified
Intellectual Disabilities Professional (RN/QIDP)
revealed staff should close the door for client #2
during personal care to ensure her privacy.

W 249 | PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan.

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

W 130

W 249

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:X4H011

Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 08/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

This STANDARD is not met as evidenced by:
Based on observations, record review and
interview, the facility failed to ensure 1 of 5 audit
clients (#5) at Hawksbill received a continuous
active treatment program consisting of needed
interventions as identified in the person-centered
plan (PCP). The finding is:

Observations in the group home on 8/12/25
revealed client #5 to wear a gait belt and for staff
to ambulate client around the home utilizing his
gait belt. Continued observation at 4:22 PM
revealed staff to ambulate client #5 next door to
Beaucatcher utilizing their gait belt only. Further
observations at 5:15 PM revealed staff to
ambulate client #5 back to Hawksbill utilizing their
gait belt only. Additional observations in the group
home revealed a walker to be sitting in the
hallway corner.

Review of client #5's record on 8/13/25 revealed
a PCP dated 8/7/25 which indicated a habilitation
program for physical therapy exercise, to include
gait training, seated exercises, and standing
exercises. Continued review of client #5's record
revealed a physical therapy (PT) evaluation dated
7/10/25. Review of the PT evaluation indicated
client #5 is prescribed a gait belt, walker, and
wheelchair for long distances. Continued review
of the PT evaluation indicated client #5 ambulates
with a walker and gait belt with standby to
minimal assistance.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/13/25 confirmed client
#5's PCP and PT recommendations are current.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:X4H011

(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 249 | Continued From page 1 W 249

Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 08/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/13/2025

CFR(s): 483.480(b)(2)\(iii)

Food must be served in a form consistent with the
developmental level of the client.

This STANDARD is not met as evidenced by:
Based on observations, record review and
interview, the facility failed to ensure food was
served in a form consistent with the
developmental level of 1 of 5 audit clients (#5) at
Hawksbill. The finding is:

Observations in the group home on 8/12/25 at
4:00 PM revealed client #5 to participate in group
snack. Continued observations revealed client #5
to choose Cheeto Puffs and for staff to serve
them cut in half. Observation of the dinner meal
at 5:34 PM revealed it to include Greek pasta,
marinated cucumbers and onions, green beans,
sliced orange and pineapple, milk and water.
Additional observation revealed client #5 to be
served the dinner meal in whole form and to
participate independently in the dinner meal.

Observations in the group home on 8/13/25 at
7:06 AM revealed the breakfast meal to include
scrambled eggs, grits, Greek yogurt, mixed
berries, milk and coffee. Continued observations
revealed client #5 to be served the breakfast
meal in whole form and to participate
independently in the breakfast meal.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:X4H011

(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 249 | Continued From page 2 W 249
Continued interview with the QIDP revealed client
#5 has made progress with ambulation and the
walker is not always needed while in the home.
Further interview with the QIDP revealed staff are
supposed to support client #5 with ambulation
utilizing his walker anytime he leaves the home.
W 474 | MEAL SERVICES W 474

Facility ID: 922418

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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 08/14/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION

Review of client #5's records on 8/13/25 revealed
a nutritional assessment dated 8/1/24 which
indicated their diet order to be regular, finely
chopped.

Interview with qualified intellectual disabilities
professional (QIDP) on 8/13/25 confirmed the diet
order for client #5 is current. Continued interview
with the QIDP verified finely chopped consistency
should be less than one quarter inch with certain
foods minimally processed in a food processor,
depending on texture. Further interview with the
QIDP confirmed staff are responsible for ensuring
clients receive their diet orders as prescribed.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:X4H011

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (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 474 | Continued From page 3 W 474

Facility ID: 922418 If continuation sheet Page 4 of 4


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 12/31/2024
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING COMPLETED
Cc
BWING 12/30/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(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
Acomplaint survey was completed on 12/30/24
for intake #NC00225434. The allegation was
unsubstantiated. No deficiencies were cited.
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: FIGC11

Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Complaint


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: 10/31/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

A. BUILDING
R

10/30/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

(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
Arevisit was conducted on 10/30/24 for all
previous deficiencies cited on 8/20/24. All
deficiencies were corrected and no new
non-compliance 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: 1¥C012

Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/20/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION (x8)

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

DEFICIENCY)

E 037 | EP Training Program
CFR(s): 483.475(d)(1)

§403.748(d)(
§441.184(d)(
§483.73(d)(1
§485.68(d)(1
§485.727(d)(
§491.12(d)(1

1), §416.54(d)(1), §418. 113(d)(1),
1), §460.84(d)(1), §482.15(d)(1),

), §483.475(d)(1), §484.102(d)(1),

), §485.542(d)(1), §485.625(d)(1),
1), §485.920(d)(1), §486.360(d)(1),
).

*[For RNCHIs at §403.748, ASCs at §416.54,
Hospitals at §482.15, ICF/IIDs at §483.475, HHAs
at §484.102, REHs at §485.542, "Organizations"
under §485.727, OPOs at §486.360,
RHC/FQHCs at §491.12:]

(1) Training program. The [facility] must do all of
the following:

(i) Initial training in emergency preparedness
policies and procedures to all new and existing
staff, individuals providing services under
arrangement, and volunteers, consistent with their
expected roles.

(ii) Provide emergency preparedness training at
least every 2 years.

(iii) Maintain documentation of all emergency
preparedness training.

(iv) Demonstrate staff knowledge of emergency
procedures.

(v) If the emergency preparedness policies and
procedures are significantly updated, the [facility]
must conduct training on the updated policies and
procedures.

*[For Hospices at §418.113(d):] (1) Training. The
hospice must do all of the following:

(i) Initial training in emergency preparedness
policies and procedures to all new and existing
hospice employees, and individuals providing
services under arrangement, consistent with their
expected roles.

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

E 037

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: 1¥C011

Facility ID: 922418 If continuation sheet Page 1 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/20/2024

(ii) Demonstrate staff knowledge of emergency
procedures.

(iii) Provide emergency preparedness training at
least every 2 years.

(iv) Periodically review and rehearse its
emergency preparedness plan with hospice
employees (including nonemployee staff), with
special emphasis placed on carrying out the
procedures necessary to protect patients and
others.

(v) Maintain documentation of all emergency
preparedness training.

(vi) If the emergency preparedness policies and
procedures are significantly updated, the hospice
must conduct training on the updated policies and
procedures.

*[For PRTFs at §441.184(d):] (1) Training
program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness
policies and procedures to all new and existing
staff, individuals providing services under
arrangement, and volunteers, consistent with their
expected roles.

(ii) After initial training, provide emergency
preparedness training every 2 years.

(iii) Demonstrate staff knowledge of emergency
procedures.

(iv) Maintain documentation of all emergency
preparedness training.

(v) If the emergency preparedness policies and
procedures are significantly updated, the PRTF
must conduct training on the updated policies and
procedures.

*[For PACE at §460.84(d):] (1) The PACE
organization must do all of the following:
(i) Initial training in emergency preparedness

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

(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)
E 037 | Continued From page 1 E 037

Facility ID: 922418

If continuation sheet Page 2 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 08/21/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(X3) DATE SURVEY

COMPLETED

08/20/2024

policies and procedures to all new and existing
staff, individuals providing on-site services under
arrangement, contractors, participants, and
volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at
least every 2 years.

(iii) Demonstrate staff knowledge of emergency
procedures, including informing participants of
what to do, where to go, and whom to contact in
case of an emergency.

(iv) Maintain documentation of all training.

(v) If the emergency preparedness policies and
procedures are significantly updated, the PACE
must conduct training on the updated policies and
procedures.

*[For LTC Facilities at §483.73(d):] (1) Training
Program. The LTC facility must do all of the
following:

(i) Initial training in emergency preparedness
policies and procedures to all new and existing
staff, individuals providing services under
arrangement, and volunteers, consistent with their
expected role.

(ii) Provide emergency preparedness training at
least annually.

(iii) Maintain documentation of all emergency
preparedness training.

(iv) Demonstrate staff knowledge of emergency
procedures.

*[For CORFs at §485.68(d):](1) Training. The
CORF must do all of the following:

(i) Provide initial training in emergency
preparedness policies and procedures to all new
and existing staff, individuals providing services
under arrangement, and volunteers, consistent
with their expected roles.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

(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)
E 037 | Continued From page 2 E 037

Facility ID: 922418

If continuation sheet Page 3 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/20/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

(ii) Provide emergency preparedness training at
least every 2 years.

(iii) Maintain documentation of the training.

(iv) Demonstrate staff knowledge of emergency
procedures. All new personnel must be oriented
and assigned specific responsibilities regarding
the CORF's emergency plan within 2 weeks of
their first workday. The training program must
include instruction in the location and use of
alarm systems and signals and firefighting
equipment.

(v) If the emergency preparedness policies and
procedures are significantly updated, the CORF
must conduct training on the updated policies and
procedures.

*[For CAHs at §485.625(d):] (1) Training program.
The CAH must do all of the following:

(i) Initial training in emergency preparedness
policies and procedures, including prompt
reporting and extinguishing of fires, protection,
and where necessary, evacuation of patients,
personnel, and guests, fire prevention, and
cooperation with firefighting and disaster
authorities, to all new and existing staff,
individuals providing services under arrangement,
and volunteers, consistent with their expected
roles.

(ii) Provide emergency preparedness training at
least every 2 years.

(iii) Maintain documentation of the training.

(iv) Demonstrate staff knowledge of emergency
procedures.

(v) If the emergency preparedness policies and
procedures are significantly updated, the CAH
must conduct training on the updated policies and
procedures.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

(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)
E 037 | Continued From page 3 E 037

Facility ID: 922418 If continuation sheet Page 4 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

(x4) ID
PREFIX
TAG

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

08/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE

SWANNANOA, NC 28778
ID PROVIDER'S PLAN OF CORRECTION

PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(8)
COMPLETION
DATE

E 037 | Continued From page 4

*[For CMHCs at §485.920(d):] (1) Training. The
CMHC must provide initial training in emergency
preparedness policies and procedures to all new
and existing staff, individuals providing services
under arrangement, and volunteers, consistent
with their expected roles, and maintain
documentation of the training. The CMHC must
demonstrate staff knowledge of emergency
procedures. Thereafter, the CMHC must provide
emergency preparedness training at least every 2
years.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure direct care staff were trained on
the facility's emergency preparedness plan (EPP)
at least biennially. The finding is:

Review on 8/19/24 of the facility's EPP revealed
no evidence of initial or biennial training on the
EPP.

Interview on 8/20/24 with the qualified intellectual
disabilities professional (QIDP) verified that there
was no evidence available to document initial and
biennial trainings for current staff.

PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

W 249

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

E 037

W 249

Facility ID: 922418 If continuation sheet Page 5 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/20/2024

(x4) ID
PREFIX
TAG

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

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

(8)
COMPLETION
DATE

DEFICIENCY)

W 249 | Continued From page 5

This STANDARD is not met as evidenced by:
Based on observations, record review and
interview, the facility failed to ensure 1 of 8 clients
in Hawksbill (#3) received a continuous active
treatment program consisting of needed
interventions relative to mealtime adaptive
equipment. The finding is:

Observations throughout the 8/19-20/24 survey
revealed client #3 to participate in the breakfast
and dinner meal independently. Continued
observations revealed client #3 to utilize the
following adaptive equipment for both meals:
high-sided divided dish, shirt protector, sip cup,
and non-skid mat.

Review of client #3's record on 8/20/24 revealed
an occupational therapy (OT) evaluation dated
6/24/24. Review of the OT evaluation indicated
recommendations for client #3's mealtime
adaptive equipment to include a high-sided
divided dish, shirt protector, sip cup, non-skid
mat, and lateral wedge/roll for right side.
Continued review of client #3's record revealed
no order to discontinue the lateral wedge/roll for
right side.

Interview with the qualified intellectual disability
professional (QIDP) on 8/20/24 confirmed client
#3's OT evaluation is current. Continued interview
revealed the lateral wedge/roll is no longer being
utilized due to client #3 not tolerating it, however it
has not been formally discontinued. Further
interview confirmed staff should offer and support
client #3's adaptive equipment.

SPACE AND EQUIPMENT

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

W 436

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

W 249

W 436

Facility ID: 922418

If continuation sheet Page 6 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 08/21/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/20/2024

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 observations, record review and
interview, the facility failed to ensure that
prescribed adaptive equipment was maintained
for 1 of 7 clients at Beaucatcher (#1). The finding
Is:

Observation in the group home during the
recertification survey on 8/19-20/24 revealed
client #1 to maneuver around the dining room
area in a wheelchair independently and with staff
assistance. Continued observations revealed
client #1's wheelchair to have exposed foam on
the right arm rest and a piece of cloth tied to the
arm rest. Further observations revealed client #1
to sit slightly slumped in her wheelchair.

Review of records for client #1 on 8/20/24
revealed an individual support plan (ISP) dated
6/25/24. Continued review of ISP revealed a
physical therapy (PT) evaluation dated 6/4/24 for
client #1. Further review of the PT evaluation
revealed that on 5/2024 client #1 was provided a
new wheelchair/seating with the wrong thigh
positioner.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/20/24 confirmed client
#1's PT evaluation was current. Continued
interview with the QIDP revealed that client #1
was scheduled to have a new wheelchair in
January or February 2024; however, the facility

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

(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 6 W 436

Facility ID: 922418

If continuation sheet Page 7 of 8

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

SUMMARY STATEMENT OF DEFICIENCIES

PRINTED: 08/21/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

08/20/2024

(x5)

could not get the funding. Further interview with
the QIDP revealed that client #1's right broken
arm rest and hip abduction pillow modifications
were ordered and should be replaced; however,
the facility provided no evidence of the order.

(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)
W 436 | Continued From page 7 W 436

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1¥C011

Facility ID: 922418

If continuation sheet Page 8 of 8


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

PRINTED: 04/29/2024
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
Cc
346089 04/25/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL
SWANNANOA, NC 28778
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000
A complaint survey was completed on April 25,
2024, for intake #NC00214707 and
#NC00214716. Intake #NC00214707 complaint
was substantiated without deficiency. Intake
#NC00214716 complaint was unsubstantiated
without deficiency.
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:OTV811 Facility ID: 922418 If continuation sheet Page 1 of 1


raw_content:
PRINTED: 11/14/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

(X3) DATE SURVEY

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
34G089 11/14/2023

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(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)
E 000 | Initial Comments E 000

A follow-up survey was completed on 11/14/2023
for previous deficiencies cited on 09/06/2023. All
deficiencies have been corrected and no new
non-compliance 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: E1x412 Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

PRINTED: 09/07/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
09/06/2023

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

ID PROVIDER'S PLAN OF CORRECTION (x8)

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

DEFICIENCY)

W 000 | INITIAL COMMENTS

A recertification survey and complaint survey for
Intake #NC00205227 was completed on 9/6/23.
The complaint was unsubstantiated and no
deficiencies were cited. However, deficiencies
were cited for the recertification survey.

W 252 | PROGRAM DOCUMENTATION

CFR(s): 483.440(e)(1)

Data relative to accomplishment of the criteria
specified in client individual program plan
objectives must be documented in measurable
terms.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure data relative to accomplishment
of the criteria specified in the individual support
plan (ISP) objectives for 1 of 1 sampled client
(#15) at Pisgah was documented in measurable
terms. The finding is:

Review of records for client #15 on 9/6/23
revealed an ISP dated 1/10/23. Review of the ISP
indicated client #15's habilitation goals to include
completing a personal appearance checklist,
completing one chore after dinner, assist with
making one side dish for dinner, correctly
identifying items needed when making choices,
and participation in walking exercise and
medication administration. Continued review of
client #15's record revealed no data to be
collected on their progress for the month of
September 2023. Further review revealed large
gaps in data collection from June 2023 to August
2023.

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

W 000

W 252

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: E1x411

Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 09/07/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
09/06/2023

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

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

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.
This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to assure all drugs
were administered without error for 1 of 8 clients
(#23) observed during medication administration
at Beaucatcher. The finding is:

Observation in the group home on 9/6/23 at 7:57
AM revealed staff A to remove medications from
cart, obtain apple sauce, sanitize hands, and to
educate client on medications. Continued
observation revealed staff A to assist client #23
with punching prescribed medications
Furosemide 40 MG tab and Potassium ER 10
MEQ tab into a medicine cup. Further
observation revealed staff A to place the medicine
cup containing client #23's medications into a
crusher and crush the tablets. Subsequent
observations revealed staff to pour the
medications into apple sauce and pour water into
acup. Additionally, client #23 ate the apple
sauce containing the medications and drank the
cup of water.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EIx411

(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 252 | Continued From page 1 W 252
Review of facility records on 9/6/23 revealed an
administrative assessment dated 8/30/23 which
indicated "insufficient" data collection at Pisgah.
Interview with the Qualified Intellectual Disability
Professional on 9/6/23 revealed staff should be
recording data daily for each client.
W 369 | DRUG ADMINISTRATION W 369

Facility ID: 922418 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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(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

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PRINTED: 09/07/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
09/06/2023

ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

W 369 | Continued From page 2

Review of records for client #23 on 9/6/23
revealed physician orders dated 9/1/23. Review
of the 6/1/23 physician orders revealed
medications to administer at 8:00 AM to be
Furosemide 40 MG tab, Metronidazole Topical
1%, Voltaren 1% Gel, and Potassium ER 10
MEQ* tab - take 1 tablet by mouth every day “DO
NOT CRUSH*. During survey observation staff A
was observed to administer client #23's
Potassium ER 10 MEQ* tab by crushing the
tablet and pouring it into apple sauce.

Interview with the facility nurse on 9/6/23
confirmed the 9/1/23 physician orders for client
#23 to be current. Continued interview with the
facility nurse revealed that staff should administer
medications as prescribed, and staff should
contact nursing if instructions for administering
medications conflict with the client's medication
face sheet and physician orders.

W 382 | DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(1)(2)

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

This STANDARD is not met as evidenced by:
Based on observations and interviews, the facility
failed to ensure all drugs and biologicals were
kept locked except when being prepared for
administration for 5 of 7 clients (#10, #11, #12,
#13, and #15) at Pisgah. The finding is:

Observations in the group home during the
9/5-6/23 survey revealed prescription medications
to be accessible in toiletry totes in the bathrooms
of clients #10, #11, #12, #13, and #15 for both
survey days.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EIx411

W 369

W 382

Facility ID: 922418

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:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 09/07/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
09/06/2023

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

Interview with the facility nurse and nurse
supervisor on 9/6/23 confirmed staff are
responsible for ensuring all prescription
medications are kept locked except when being
prepared for administration.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EIx411

(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 382 | Continued From page 3 W 382

Facility ID: 922418 If continuation sheet Page 4 of 4


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 12/01/2022
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346089 B. WING 11/30/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL 91 POPLAR CIRCLE
. SWANNANOA, NC 28778
(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 11/30/22 for all
previous deficiencies cited on 9/20/22. All
deficiencies were corrected and no new
non-compliance 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:E30212

Facility ID: 922418 If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 09/23/2022
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

B, WING

346089 09/20/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANDA, NC 28778
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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)

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PROTECTION OF CLIENTS RIGHTS
CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure privacy during
treatment and care of personal needs.

This STANDARD is not met as evidenced by:
The facility failed to ensure the privacy of 1 of 7
clients residing in Hawksbill (#10) during care of
personal needs as evidenced by observations
and interviews. The finding is:

Morning observations in Hawksbill on 9/20/22 at
6:25 AM revealed 2 staff exiting a bedroom and
crossing the hall with client #10 sitting naked in a
shower chair. Staff then entered client #10's
bedroom and assisted the client with getting

| dressed for the day. Interview with staff revealed

currently all clients in Hawsbill are using one

shower located in the bathroom which only has
access by walking through the bedrooms of
clients. Further interview with staff and the
qualified intellectual disabilities professional

(QIDP) revealed that client #10 likes to be

dressed in his bedroom but staff should ensure

the privacy of clients when they are walking
through the bedrooms of other residents and in

| the common areas of the group home. | 1

W 227 | INDIVIDUAL PROGRAM PLAN W 227 DHSR - Mental Health

CFR(s): 483.440(c)(4)

OCT 11 2077

The individual program plan states the specific

| objectives necessary to meet the client's needs, ee
as identified by the comprehensive assessment Lic. & Cert. Seuiull
required by paragraph (c)(3) of this section.

This STANDARD is not met as evidenced by: | |
Based on observations, record review and
interviews, the person-centered plan (PCP) failed
io address identified needs for 1 of 8 female
Glients in Pisgah (#18). The finding is:

pedi |DER/SURPLIER REPRESENTATIVE'S SIGNATURE
MC 4

PJ
s

Any'deficienty statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it @ 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

(X6) DATE

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:E30211 Facility 1D: 922418 'f continuation sheet Page 1 of 8

PRINTED: 09/23/2022
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 BUOING COMPLETED

346089 B.WING 09/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL ST PORTAR CIRCLE
SWANNANOA, NC 28778

(x4) 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)

| Continued From page 1

Observations throughout the 9/19-20/22 survey

revealed client #18 to engage in various activities

to include "slime" making, identifying currency,

listening to music, setting the table, meal

preparation and meal participation. Continued

| observations throughout the survey period

| revealed client #18's appearance to include
noticeable facial hair. Further observations
throughout the survey revealed at no time did

| staff support or educate client #18 on the
importance of shaving her face.

Review of client #18's record on 9/20/22 revealed
a PCP dated 8/30/22. Review of client #18's PCP
indicated habilitation goals to include brush hair
with verbal prompts, brush teeth with gestural
prompts, wash hands with gestural prompts, state
the designated number of sight words 100% of
the time, show the correct bill needed to purchase
common items 100% of the time, and participate
in outings or group activities with verbal cues
during the day.

Continued review of client #18's PCP indicated

| the prevalence of anxiety and mood disorders

| has increased significantly in the past two years
to include loss of interest in personal appearance
such as shaving, showering, putting on make-up
and looking nice. Continued review of client #18's
record revealed a comprehensive functional
assessment (CFA) dated 8/30/22. Review of the

| CFA indicated client #18 has a history of
independence with activities of daily living (ADL)
and staff should encourage her to participate in
ADLs before doing a task for her and give her

| plenty of time to complete a task.

Interview with the site nurse on 9/20/22 revealed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: £30211 Facility ID: 922418 If continuation sheet Page 2 of 8

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

PRINTED: 09/23/2022
FORM APPROVED
OMB NO. 0938-0391

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

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(x4) 1D
PREFIX
TAG

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

W 227

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

| Continued From page 2

client #18 has experienced an increase in
depression over the last two years due to the
deaths of her sister and a close friend. Continued
interview with the site nurse revealed client #18
used to initiate shaving her face as part of her
hygiene routine, but has recently expressed no
desire in completing ADLs and will refuse to allow
| staff to assist with shaving. Interview with the
qualified intellectual disabilities professional
(QIDP) on 9/20/22 revealed they are aware of
client #18's refusal to shave among other hygiene
refusals. Continued interview with the QIDP
revealed they are attempting to prioritize how staff
support client #18's hygiene needs. Further
interview with the QIDP confirmed formal training
programs to promote the client's completion of
activities such as shaving would benefit client #18
in addition to supporting staff to intervene with the
| client consistently.

PROGRAM IMPLEMENTATION

CFR(s): 483.440(d)(1)

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program

| plan.

This STANDARD is not met as evidenced by:
Based on observation, interviews and record
review, the facility failed to ensure a continuous
| active treatment program consisting of needed
interventions were implemented as identified in

Event ID: £30211

(X2) MULTIPLE CONSTRUCTION |(X3) DATE SURVEY
A. BUILDING

COMPLETED

09/20/2022
STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

PROVIDER'S PLAN OF CORRECTION | 06)
(EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Facility ID: 922418 If continuation sheet Page 3 of 8

PRINTED: 09/23/2022
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

346089 WING) 09/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANDA, NC 28778

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(x4) 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)

Continued From page 3
| the person centered plan (PCP) for client #7 in
Beaucatcher Home. The finding is:

Observations in the group home on 9/20/22 from
6:40 AM - 8:30 AM revealed client #7 to
Participate in various activities in the group home.
Continued observation at 7:30 AM revealed staff
to transition client #7 from the living room to the
dining table using a gait belt and holding the client
around her shoulder. Further observations
revealed staff to sit client #7 in a dining room
chair using the gait belt and holding the client
around the waist. At no point during the

| observation did staff obtain and use client #7's

bilateral ankle foot orthoses (AFO) shoe inserts

and bilateral knee braces.

Review of the record for client #7 on 9/20/22
revealed a PCP dated 6/23/22. Continued review
of the record revealed an occupational (OT)
evaluation dated 5/16/22 which states that client
#7 has the following adaptive equipment to
address severe planovailgus and improve lower
extremity (LE) alignment: UCB style orthotic shoe
inserts, bilateral knee braces, gait belt and
wheelchair. Review of the 5/2022 OT evaluation
revealed client #7 has walking guidelines to
address concerns with patellar dislocation,
| joint/bone health and gait safety. Review of the
physical therapy (PT) evaluation dated 5/18/22
revealed client #7 has knee orthoses to facilitate |
medical stabilization and patellar tracking control |

to help reduce or prevent episodes of knees

| buckling when walking. Review of the medical
evaluation dated 2/2/22 revealed client #7 must
wear AFOs and knee braces during all waking
hours. Staff know to check that the client's
“braces are firmly in place and in the correct
position before assisting her to ambulate”.

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID: £30211 Facility ID: 922418 If continuation sheet Page 4 of 8

PRINTED: 09/23/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

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

34G089 B, WING 09/20/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778
SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

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

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(x4) 1D
PREFIX
TAG

Continued From page 4
Review of the record did not reveal walking

guidelines during the survey to verify adaptive
equipment wear and usage.

Interview with the qualified intellectual disabilities
professional (QIDP) on 9/20/22 revealed walking
guidelines for client #7 could not be located
during the survey. The QIDP revealed during the
interview the material on the knee braces has
been giving client #7 an allergic reaction. The
QIDP also revealed staff will place the knee
braces on client #7 after breakfast and morning
shower. Continued interview with the QIDP
revealed all of client #7's programs and
interventions are current. Further interview with
the QIDP verified client #7 must wear her
adaptive equipment as prescribed to ensure joint
heaith and gait safety.

W 369 DRUG ADMINISTRATION W 369)
CFR(s): 483.460(k)(2)

The system for drug administration must assure
that all drugs, including those that are
self-administered, are administered without error.
This STANDARD is not met as evidenced by:
The facility failed to assure that medications
administered to 1 of 1 sampled clients in
Hawksbill (#14) were administered without error
as evidenced by observation and interview. The
finding is:

Morning observation in the group home on
9/20/22 revealed staff administering client #14 his |
morning medication at 8:06 AM. Further

| observations revealed staff getting client #14 to |
help punch medications from 6 different pill packs

and included the medications Ducosate Sodium |
| 100 mg, Lexapro 20 mg, Vitamin D3 400 IU,

FORM CMS-2567(02-89) Previous Versions Obsolete Event ID: £30211 Facility ID: 922418 If continuation sheet Page 5 of 8

PRINTED: 09/23/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA |(X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

34G089 09/20/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

NAME OF PROVIDER OR SUPPLIER,

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

Continued From page 5
Metformin ER 500 mg- 2 tablets, Fish Oil 1000
mg and Lisinopril 20 mg in that order. Continued
observations revealed the client was observed to
leave the medication room after taking his

| medications with water.

Review of client #14's electronic medication
administration record, substantiated by interview |
with the qualified intellectual disabilities

| professional (QIDP), revealed on 9/1/22 the client
started an additional medication for his blood
pressure, Hydrochlorothiazide 25 mg tab at 8:00

| AM. Subsequent morning observations in

| Hawksbill on 9/20/22 revealed staff failed to pull
this medication from the medication cart to
administer it to client #14 as prescribed. |
W 436 SPACE AND EQUIPMENT | W 436
CFR(s): 483.470(g)(2)

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 furnish and maintain
in good repair the use of adaptive equipment for
client (#5) in Beaucatcher Home. The finding is:

Observations during the 9/19/22-9/20/22 survey
revealed client #5 to ambulate throughout the
group home in a wheelchair. Continued
observation on 9/19/22 at 4:15 PM revealed client
#5 to show this surveyor a large Band-Aid
attached to the right arm rest of her wheelchair.
Further observations revealed client #5 to have

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID:E30211 Facility ID: 922418 If continuation sheet Page 6 of 8

PRINTED: 09/23/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING COMPLETED

346089 BWWING 09/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL
SWANNANOA, NC 28778
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs)
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)

Continued From page 6
the left arm rest covered by neon pink duct tape
to hold the arm rest in place.

Review of documentation on 9/20/22 revealed a
work order to include numerous wheelchair parts
for clients. Review of the documentation did not
reveal a work order for client #5 for new arm
rests.

Interview with staff on 9/20/22 revealed they
could not determine how long client #5's arm rest
has been torn, however management has

| ordered wheelchair parts for client #5 to include
new arm rests. Continued interview with staff
revealed the Band-Aid was put in place to ensure
| that the torn area would not scratch client #5's
skin until the arm rests could be replaced.

Interview with the qualified intellectual disabilities
professional (QIDP) revealed a work order
specific to client #5's new arm rests could not be
located during the survey. Continued interview
with the QIDP verified that all clients should have
adaptive equipment repaired and in good working
order.

EVACUATION DRILLS

CFR(s): 483.470(i)(1)

at least quarterly for each shift of personnel.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure evacuation drills were held at
least quarterly for each shift of personnel. The
finding is:

Review of fire drill records at Pisgah Home on
9/19/22 from 8/2021 to 9/2022 revealed four fire
drills were conducted during the first and second

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:E30211 Facility ID: 922418 If continuation sheet Page 7 of 8

PRINTED: 09/23/2022
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

346089 8 WING ____________ 09/20/2022
NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778
(x4) 1D 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)

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

Continued From page 7

quarters of 2022. Further review revealed 3rd
shift drills to be missing from the first and second
quarters of 2022.

Interview with the qualified intellectual disabilities
professional on 9/20/22 confirmed fire drills
should have been conducted quarterly for each
shift of personnel.

Event ID:E30211 Facility ID: 922418 If continuation sheet Page 8 of &

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

Kim Claggett, Residential Facilities Administrator
Blue West Opportunities

43 College Place, Suite 306

Asheville, NC 28803

09/29/2022

To the DHHS Survey Team:

On behalf of all the clients and the entire support team of Blue West Opportunities, thank you for the
time and energy you spent with us last week., helping us to improve our services. Enclosed you will find
our plan to correct the issues cited during the survey. We look forward to the improved outcomes you
have helped us identify. We invite you back to our agency on November 20, 2022, to review corrections

for all deficiencies cited.

Thank you again.

Sincerely,

Kim Claggett

Blue West Opportunities - Swannanoa
Plan of Correction

Survey 09/19/22 — 09/20/22

W130
Protection of Client Rights

The facility must ensure the rights of all clients. Therefore, the facility must ensure privacy during
treatment and care of personal needs. This STANDARD is not met as evidenced by: The facility failed
to ensure privacy of 1 of 7 clients residing in Hawksbill during care of personal needs as evidenced by

observation and interviews.
Responsible Person: QIDP, Site Director

Plan for Corrections: Robes will be purchase for every client on the Swannanoa site to ensure the
privacy during treatment and care of personal needs.

In an effort to provide the greatest degree of privacy for all residents given the structure of the home,
the team will evaluate the need of each resident with regard to the most appropriate tub/shower

bathroom facility.
All staff will receive re-training on privacy issues.

Mechanism to ensure compliance: Administrative Quick View Assessment, Inservice from QIDP on
Client Rights, Inventory on all residents — bath robes, copy of scomm

Frequency of mechanism: weekly in the group home

W227

The individual program plan states the specific objectives necessary to meet the client’s needs, as
identified by the comprehensive assessment required by paragraph © (3) of this section. This
standard is not met by evidenced by: Based on observation record review and interviews, the person-
centered-plan failed to address needs for # 18 of 8 females’ clients in Pisgah.

Responsible Person: QIDP and Assistant QIDP

Plan to correct and prevent future occurrences: Due to the current presentation of goals and client the
interdisciplinary team of BWO will meet and schedule a reassessment for each discipline to ensure the
goals meet the present need of sample client #18. After the assessment an effective person-centered

plan will be developed and implemented. Staff will be in-serviced by the QIDP Assistant and monitored.
The Assistant QIDP will also train on the hygiene schedule.

Mechanism to ensure compliance: Review progress towards goals including QIPD notes.

Frequency of mechanism: quarterly

w249

As soon as the interdisciplinary team has formulated a client’s individual program plan, each client
must receive a continuous active treatment program plan consisting of needed interventions and
services in sufficient number and frequency to support the achievement if the objectives identified in
the individual program.

Responsible Person: QIDP, Site Director, Motoric Clinical Specialist

Plan to correct and prevent future occurrences: Motoric Clinical Specialist will create an Inservice to
retrain staff after a reassessment from the PT/OT clarifying the method to meet the needs of client #7.

Mechanism to ensure compliance: Administrative Quick View Assessment by QIDP, Additional
Assessments by other IDT members. Any noncompliance will be corrected by the observer, reported to
the QIDP, Site Director or appropriate Supervisor for any retraining or disciplinary process.

Frequency of mechanism: weekly observations

W369

The system of drug administration must ensure that all drugs, including those that are self-
administered, are administrated without error. The standard is not met as evidenced by: The facility
failed to assure that medications administered to 1 of 1 sampled client in Hawksbill were
administered without error as evidenced by observation and interview.

Responsible Person: Director of Integrated Health Services, QIDP, Site Director

Plan to correct and prevent future occurrences: Integrated Health Services will Inservice all the med
techs in Swannanoa regarding proper medication administration procedure(s). In addition, the Director
of Integrated Health Services will create a visual flyer to remind every med tech to recheck three times
placed in medication room. Every med tech will be observed by the Director of Integrated Health
Services, the Site LPN or the QIDP for following the trained procedure of medication administration.

Mechanism to ensure compliance: Any medication errors will be reported to the IDT and reviewed after
the Integrated Health Services process of notification. Nursing reports any medication errors on the GER
in Therap to ensure appropriate reporting Quality and the MCOs.

Frequency of mechanism: Periodic medication assessment form completed by Site Directors’ after doing
random check on all medication technicians.

W436

The facility must furnish, maintain in good repair, and teach clients to use and make informed choices
about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other
devises as identified by the interdisciplinary team as needed by the client. The standard is not met as
evidenced by: Based on observation, record review and interview, the facility failed to furnish and
maintain in good repair the use of adaptive equipment for client #5 in Beaucatcher home.

Responsible Person: QIDP, Site Director, Motoric Clinical Specialist

Plan to correct and prevent future occurrences: Motoric Clinical Specialist initiated the work order for
National Seating and Mobility to assess and replace any needs for client #5 wheelchair. MCS will
Inservice at the monthly Site Meeting the appropriate process for reporting any needed repairs or
replacement of any adaptive equipment. An updated version of the third shift responsibility checklist to
include adaptive equipment repair/needs to be submitted to MCS.

Mechanism to ensure compliance: Administrative Quick View Assessment, Assessment of Adaptive
Equipment Inspection. Report any deficiencies to the QIDP. The QIDP will follow up with the appropriate
Supervisor. The Site Manager will follow up on any training or disciplinary processes. An updated version
of the third shift responsibility checklist to include adaptive equipment repair/needs to be submitted to
MCs.

Frequency of mechanism: Effectiveness will be reviewed in IDT on the six-week rotation of house
reviews. Forms to be submitted weekly to MCS.

wa44o

Evacuation Drills CFR 483.470 (i) (1) at least quarterly for each shift of personnel. This standard is not
met as evidenced by record review and interview, the facility failed to ensure evacuation drills were
held at least quarterly for each shift of personnel.

Responsible Person: Site Director

Plan to correct and prevent future occurrences: Facilities Director will Inservice Supervisors, Site
Director and QIDP in the next scheduled supervisors’ meeting. To ensure that all staff are being trained
to ensure that evacuation drills scheduled are done and documented in a timely manner.

Mechanism to ensure compliance: Inservice Swannanoa, Facility Director will send out drill schedule for
each site and a written informed directive will be given weekly at staff meetings.

Frequency of mechanism: Monthly