summary: Statement of Deficiency - 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
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

A. BUILDING
34G089 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 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 130 | PROTECTION OF CLIENTS RIGHTS W 130

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.

W 227 | INDIVIDUAL PROGRAM PLAN W 227
CFR(s): 483.440(c)(4)

The individual program plan states the specific
objectives necessary to meet the client's needs,
as identified by the comprehensive assessment
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
to address identified needs for 1 of 8 female
clients in Pisgah (#18). The finding is:

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:£30211 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

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/20/2022
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

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:E30211

(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 227 | Continued From page 1 W 227

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

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

(x4) ID
PREFIX
TAG

PRINTED: 09/23/2022

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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)

ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

09/20/2022

(8)

COMPLETION
DATE

W 227 | 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)

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.

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

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:E30211

W 227

W 249

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/20/2022
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

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 planovalgus 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(02-99) Previous Versions Obsolete Event ID:E30211

(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 3 W 249

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: 09/23/2022

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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)

ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

09/20/2022

(8)

COMPLETION
DATE

W 249 | 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
health and gait safety.

DRUG ADMINISTRATION

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

W 369

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(02-99) Previous Versions Obsolete Event ID:E30211

W 249

W 369

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

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

(x4) ID
PREFIX
TAG

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/20/2022
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)

ID
PREFIX
TAG

(8)
COMPLETION
DATE

W 369 | 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.

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 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(02-99) Previous Versions Obsolete Event ID:E30211

W 369

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

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

(x4) ID
PREFIX
TAG

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/20/2022

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

W 436 | 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)

W 440

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

W 436

W 440

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

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

09/20/2022
STREET ADDRESS, CITY, STATE, ZIP CODE

91 POPLAR CIRCLE
SWANNANOA, NC 28778

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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:E30211

(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 440 | Continued From page 7 W 440

Facility ID: 922418 If continuation sheet Page 8 of 8


state: NC

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 03/09/2022

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
R-C
34G089 B.WING 03/09/2022
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 3/9/2022 for all
previous deficiencies cited on 11/10/2021 and
recited 1/26/22. 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:D60Z13 Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


raw_content:
PRINTED: 02/04/2022
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
R-C

34G089 B.WING 01/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

(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)

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

{W 000} INITIAL COMMENTS {W 000}

{W 331} NURSING SERVICES {W 331}
CFR(s): 483.460(c)

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

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
ailed to provide nursing services in accordance
with the needs of 1 of 1 sampled clients (#1) with
not ensuring appropriate monitoring and staff
raining after a medication change and a change
in client health status. The finding is:

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21.
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
he scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

Interview with the facility administrator on
11/10/21 revealed client #1 was currently ina
nursing facility due to the need for a higher level
of care after a recent hospitalization. Continued
interview with the administrator revealed client #1
was recently released from the hospital, after a
change in health status, with a permanent
catheter and currently required restraints to keep
the client from pulling the catheter out. Further
interview with the facility administrator revealed
due to the need for a permanent catheter and
client #1's need for restraints to prevent pulling
the catheter out the team had made the decision

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:D60Z12 Facility ID: 922418 If continuation sheet Page 1 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

the clients' needs could not be met internally and
client #1 would need a different level of care upon
hospital discharge.

Areview of incident reports for client #1 from
10/22 through 10/25/21 revealed the following:

On 10/22/21 Client #1 experienced a fall without
injury. Continued review of the 10/22/21 incident
report revealed nursing assessed the client on
10/22/21 regarding the fall.

On 10/23/21 (5:00 PM) client #1 was sitting on
the floor and staff assisted the client back to his
feet and client #1 continued to walk around.
Continued review of the 10/23/21 incident report
revealed client #1 continued to fall several times
over the next 30 to 40 minutes. Further review
revealed staff tried to put shoes on client #1
thinking the client was having a traction issue and
the client continued to fall. Subsequent review
revealed staff was able to get client #1 toa
recliner where the client sat waiting for his dinner
meal. Additional review of the 10/23/21 incident
report revealed staff contacted a supervisor at
5:30 PM although no notification of nursing was
documented.

On 10/24/21 (5:30 AM) While changing client #1
in bed, the client would not stand and it was
noticed his scrotum was purplish in color.
Continued review of the 10/24/21 incident report
revealed nursing was contacted and client #1 was
sent out to the local emergency room. Further
review revealed client #1 returned to the facility
around 2:45 PM after going out for medical
evaluation and had no new orders or diagnosis.

On 10/25/21 client #1 awoke at 2:05 AM and felt
Event ID:D60Z12

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

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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 331} Continued From page 1 {W 331}

Facility ID: 922418 If continuation sheet Page 2 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

warm. Staff called on call nursing and was
directed to give the client a cool shower. When
the client awoke his temperature was 102.6 and
had a foul smell to his urine. Temperature went
down to 101.3 with shower and continued to rise
after shower and while getting dressed. Nursing
was called and directed to call EMS; Client #1
was picked up at 3:55 AM and on call nurse
would meet client at the hospital.

Review of an internal incident summary dated
10/28/21 revealed client #1 was taken into
surgery with medical evaluation on 10/25/21 to
evaluate needs due to significant swelling of the
scrotum area. This resulted in the placement of a
super pubic catheter. A review of conclusions
from the internal incident summary revealed client
#1 has experienced significant deterioration over
the past year that has accelerated during the last
few months. Continued review of conclusions
revealed although there remains no definitive
diagnosis, client #1's decline is consistent with a
neurological condition caused by repeated head
trauma. Client #1 has a lifetime history of head
banging behavior. The currently witnessed
balance issues indicate further decline. Further
review of the internal incident summary revealed
it is clear that the trauma to his bottom is likely a
result of falls experienced on 10/23/21.

Review of records for client #1 on 11/10/21
revealed a person centered plan (PCP) dated
6/14/21. Review of client #1's PCP revealed the
client to be non-verbal. Continued review of the
PCP revealed a health service goal to monitor
side effects of medications. A review of
medication side effects listed in the health service
goal revealed Risperdal to be associated with

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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 331} Continued From page 2 {W 331}

insomnia, dry mouth, headache, fatigue and

Facility ID: 922418 If continuation sheet Page 3 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

dizziness.

nterview with the facility qualified intellectual
disabilities professional (QIDP) on 11/10/21
verified client #1 was on general supervision and
he facility had (3) staff on shift at the time of the
incident of multiple falls on 10/23/21.

nterview with the facility QIDP and nursing on
11/10/21 revealed client #1 had been ordered a
medication change on 10/22/21 that reduced the
client #1's Resperidone dose from 6mg to 4mg
daily. Continued interview with the QIDP and
acility nurse verified prior to client #1's
documented fall on 10/22/21 that the client was
not known to have falls and neither the QIDP or
nurse could recall the last fall client #1 had
experienced prior to 10/22/21. Further interview
with the facility nurse verified she had not
conducted any additional training with staff after
client #1's medication change or initial fall on
10/22/21 to support or monitor a change in health
needs of the client.

A follow-up survey was conducted on 1/26/22.
Review of internal records on 1/26/22 relative to
the facility's Plan of Correction (POC) dated
12/3/21 revealed no evidence of in-service
trainings related to nursing services, including
incident review and response and timely reporting
of changes in client condition.

Interview with the residential program
administrator on 1/26/22 confirmed no in-service
trainings relative to nursing services had been
completed as indicated in the POC. Continued
interview with the residential program
administrator confirmed he would include a
review process in the next POC to ensure all

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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 331} Continued From page 3 {W 331}

Facility ID: 922418 If continuation sheet Page 4 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

CFR(s): 483.460(c)(5)(i)

Nursing services must include implementing with
other members of the interdisciplinary team,
appropriate protective and preventive health
measures that include, but are not limited to
raining clients and staff as needed in appropriate
health and hygiene methods.

This STANDARD is not met as evidenced by:
Based on record review and staff interview,
nursing failed to provide staff training relative to
imely reporting and changing health needs. The
inding is:

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21.
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
he scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

Areview of incident reports for client #1 from
10/22 through 10/25/21 revealed the following:

On 10/22/21 Client #1 experienced a fall without
injury. Continued review of the 10/22/21 incident
report revealed nursing assessed the client on
10/22/21 regarding the fall.

On 10/23/21 (5:00 PM) client #1 was sitting on
the floor and staff assisted the client back to his
feet and client #1 continued to walk around.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 331} Continued From page 4 {W 331}
future correction plans are implemented in a
timely manner.
{W 340} NURSING SERVICES {W 340}

Facility ID: 922418 If continuation sheet Page 5 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

Continued review of the 10/23/21 incident report
revealed client #1 continued to fall several times
over the next 30 to 40 minutes. Further review
revealed staff tried to put shoes on client #1
thinking the client was having a traction issue and
the client continued to fall. Subsequent review
revealed staff was able to get client #1 toa
recliner where the client sat waiting for his dinner
meal. Additional review of the 10/23/21 incident
report revealed staff contacted a supervisor at
5:30 PM although no notification of nursing was
documented.

On 10/24/21 (530 AM) While changing client #1 in
bed, the client would not stand and it was noticed
his scrotum was purplish in color. Continued
review of the 10/24/21 incident report revealed
nursing was contacted and client #1 was sent out
to the local emergency room. Further review
revealed client #1 returned to the facility around
2:45 PM after going out for medical evaluation
and had no new orders or diagnosis.

On 10/25/21 client #1 awoke at 2:05 AM and felt
warm. Staff called on call nursing and was
directed to give the client a cool shower. When
the client awoke his temperature was 102.6 and
had a foul smell to his urine. Temperature went
down to 101.3 with shower and continued to rise
after shower and while getting dressed. Nursing
was called and directed to call EMS; Client #1
was picked up at 3:55 AM and on call nurse
would meet client at the hospital.

Interview with nursing on 11/10/21 verified there
had been no call from staff on 10/23/21 relative to
the multiple falls experienced by client #1. The
facility nurse further confirmed staff did not call
nursing until 10/24/21 due to concerns with client

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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 340} Continued From page 5 {W 340}

Facility ID: 922418 If continuation sheet Page 6 of 7

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

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

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 02/04/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
RC
BWING 01/26/2022

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

#1's swollen area of the scrotum. Subsequent
interview with the facility nurse verified nursing
should have been called with the falls of client #1
on 10/23/21. Additional interview verified nursing
had provided no additional training relative to
imely reporting of a change in client health status
since 10/23/21 when staff failed to report multiple
alls of client #1.

A follow-up survey was conducted on 1/26/22.
Review of internal records on 1/26/22 relative to
he facility's Plan of Correction (POC) dated
12/3/21 revealed no evidence of in-service
rainings related to nursing services, including
incident review and response and timely reporting
of changes in client condition.

nterview with the residential program
administrator on 1/26/22 confirmed no in-service
rainings relative to nursing services had been
completed as indicated in the POC. Continued
interview with the residential program
administrator confirmed he would include a
review process in the next POC to ensure all
uture corrections are implemented in a timely
manner.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z12

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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 340} Continued From page 6 {W 340}

Facility ID: 922418 If continuation sheet Page 7 of 7


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 02/04/2022

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
R-C
34G089 re 01/26/2022

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 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 (W003 *see afty chad ter 2/esf22

Corpechongs

{W 331} NURSING SERVICES {W 331}
CFR(s): 483.460(c)

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

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to provide nursing services in accordance
with the needs of 1 of 1 sampled clients (#1) with
not ensuring appropriate monitoring and staff
training after a medication change and a change
in client health status. The finding is:

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21.
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
the scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

Interview with the facility administrator on
11/10/21 revealed client #1 was currently in a
nursing facility due to the need for a higher level
of care after a recent hospitalization. Continued

interview with the administrator revealed client #1 RECEIVED
was recently released from the hospital, after a

change in health status, with a permanent

catheter and currently required restraints to keep FEB a 3 2022

the client from pulling the catheter out. Further DHSR-MH Licensure Sect

interview with the facility administrator revealed
due to the need for a permanent catheter and
client #1's need for restraints to prevent pulling
the catheter out the team had made the decision

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

aa 1 7
Povek By is coe. be Sdendial ape Ave Alen as trator CZ M3 fer
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(02-98) Previous Versions Obsolete Event ID. 060212 Facility ID: 922418 If continuation sheet Page 1 of 7

Derek Briscoe, Program Administrator
BlueWest Opportunities

43 College Place Suite 306

Asheville, NC 28803

2/13/2021
To the DHHS survey team:

On behalf of all the clients and the entire support team at BlueWest Opportunities, thank you for the
time and energy you spent with us on November 11, 2021, and on January 26, 2022, helping us to
improve our services. Following, you will find our plan to correct the issues cited during the survey and
follow-up survey. We look forward to the improved outcomes you have helped us to identify.

We will be prepared by February 25, 2022 to review corrections for both deficiencies cited.

Thank you again.

Sincerely,
c

Derek Briscoe

appropriate protective and preventive health measures that include, but are not limited to training
clients and staff as needed in appropriate health and hygiene methods.

Responsible persons: Residential Program Administrator, Quality Assurance Manager
Mechanism to ensure compliance: Regular review of incident reports

Frequency of mechanism: At least weekly

inspection_type: MHLCS Annual

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 11/22/2021
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
c
34G089 11/10/2021

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 (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 Ww 000

Intake # NC00183002, NC00183341
W 331 | NURSING SERVICES W 331
CFR(s): 483.460(c)

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

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to provide nursing services in accordance
with the needs of 1 of 1 sampled clients (#1) with
not ensuring appropriate monitoring and staff
training after a medication change and a change
in client health status. The finding is:

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21.
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
the scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

Interview with the facility administrator on
11/10/21 revealed client #1 was currently ina
nursing facility due to the need for a higher level
of care after a recent hospitalization. Continued
interview with the administrator revealed client #1
was recently released from the hospital, after a
change in health status, with a permanent
catheter and currently required restraints to keep
the client from pulling the catheter out. Further
interview with the facility administrator revealed
due to the need for a permanent catheter and
client #1's need for restraints to prevent pulling
the catheter out the team had made the decision

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:D60Z11 Facility ID: 922418 If continuation sheet Page 1 of 6

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

the clients' needs could not be met internally and
client #1 would need a different level of care upon
hospital discharge.

A review of incident reports for client #1 from
10/22 through 10/25/21 revealed the following:

On 10/22/21 Client #1 experienced a fall without
injury. Continued review of the 10/22/21 incident
report revealed nursing assessed the client on
10/22/21 regarding the fall.

On 10/23/21 (5:00 PM) client #1 was sitting on
the floor and staff assisted the client back to his
feet and client #1 continued to walk around.
Continued review of the 10/23/21 incident report
revealed client #1 continued to fall several times
over the next 30 to 40 minutes. Further review
revealed staff tried to put shoes on client #1
thinking the client was having a traction issue and
the client continued to fall. Subsequent review
revealed staff was able to get client #1 toa
recliner where the client sat waiting for his dinner
meal. Additional review of the 10/23/21 incident
report revealed staff contacted a supervisor at
5:30 PM although no notification of nursing was
documented.

On 10/24/21 (5:30 AM) While changing client #1
in bed, the client would not stand and it was
noticed his scrotum was purplish in color.
Continued review of the 10/24/21 incident report
revealed nursing was contacted and client #1 was
sent out to the local emergency room. Further
review revealed client #1 returned to the facility
around 2:45 PM after going out for medical
evaluation and had no new orders or diagnosis.

On 10/25/21 client #1 awoke at 2:05 AM and felt

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

Event ID:D60Z11

(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 331 | Continued From page 1 W 331

Facility ID: 922418 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/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

warm. Staff called on call nursing and was
directed to give the client a cool shower. When
the client awoke his temperature was 102.6 and
had a foul smell to his urine. Temperature went
down to 101.3 with shower and continued to rise
after shower and while getting dressed. Nursing
was called and directed to call EMS; Client #1
was picked up at 3:55 AM and on call nurse
would meet client at the hospital.

Review of an internal incident summary dated
10/28/21 revealed client #1 was taken into
surgery with medical evaluation on 10/25/21 to
evaluate needs due to significant swelling of the
scrotum area. This resulted in the placement of a
super pubic catheter. A review of conclusions
from the internal incident summary revealed client
#1 has experienced significant deterioration over
the past year that has accelerated during the last
few months. Continued review of conclusions
revealed although there remains no definitive
diagnosis, client #1's decline is consistent with a
neurological condition caused by repeated head
trauma. Client #1 has a lifetime history of head
banging behavior. The currently witnessed
balance issues indicate further decline. Further
review of the internal incident summary revealed
it is clear that the trauma to his bottom is likely a
result of falls experienced on 10/23/21.

Review of records for client #1 on 11/10/21
revealed a person centered plan (PCP) dated
6/14/21. Review of client #1's PCP revealed the
client to be non-verbal. Continued review of the
PCP revealed a health service goal to monitor
side effects of medications. A review of
medication side effects listed in the health service
goal revealed Risperdal to be associated with

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z11

(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 331 | Continued From page 2 W 331

insomnia, dry mouth, headache, fatigue and

Facility ID: 922418 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/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: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

W 331 | Continued From page 3

dizziness.

Interview with the facility qualified intellectual
disabilities professional (QIDP) on 11/10/21
verified client #1 was on general supervision and
the facility had (3) staff on shift at the time of the
incident of multiple falls on 10/23/21.

Interview with the facility QIDP and nursing on
11/10/21 revealed client #1 had been ordered a
medication change on 10/22/21 that reduced the
client #1's Resperidone dose from 6mg to 4mg
daily. Continued interview with the QIDP and
facility nurse verified prior to client #1's
documented fall on 10/22/21 that the client was
not known to have falls and neither the QIDP or
nurse could recall the last fall client #1 had
experienced prior to 10/22/21. Further interview
with the facility nurse verified she had not
conducted any additional training with staff after
client #1's medication change or initial fall on
10/22/21 to support or monitor a change in health
needs of the client.

NURSING SERVICES

CFR(s): 483.460(c)(5)(i)

W 340

Nursing services must include implementing with
other members of the interdisciplinary team,
appropriate protective and preventive health
measures that include, but are not limited to
training clients and staff as needed in appropriate
health and hygiene methods.

This STANDARD is not met as evidenced by:
Based on record review and staff interview,
nursing failed to provide staff training relative to
timely reporting and changing health needs. The
finding is:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z11

W 331

W 340

Facility ID: 922418 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/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21.
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
the scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

A review of incident reports for client #1 from
10/22 through 10/25/21 revealed the following:

On 10/22/21 Client #1 experienced a fall without
injury. Continued review of the 10/22/21 incident
report revealed nursing assessed the client on
10/22/21 regarding the fall.

On 10/23/21 (5:00 PM) client #1 was sitting on
the floor and staff assisted the client back to his
feet and client #1 continued to walk around.
Continued review of the 10/23/21 incident report
revealed client #1 continued to fall several times
over the next 30 to 40 minutes. Further review
revealed staff tried to put shoes on client #1
thinking the client was having a traction issue and
the client continued to fall. Subsequent review
revealed staff was able to get client #1 toa
recliner where the client sat waiting for his dinner
meal. Additional review of the 10/23/21 incident
report revealed staff contacted a supervisor at
5:30 PM although no notification of nursing was
documented.

On 10/24/21 (530 AM) While changing client #1 in
bed, the client would not stand and it was noticed
his scrotum was purplish in color. Continued
review of the 10/24/21 incident report revealed
nursing was contacted and client #1 was sent out

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z11

(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 340 | Continued From page 4 W 340

Facility ID: 922418 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

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G089
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

PRINTED: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
11/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

to the local emergency room. Further review
revealed client #1 returned to the facility around
2:45 PM after going out for medical evaluation
and had no new orders or diagnosis.

On 10/25/21 client #1 awoke at 2:05 AM and felt
warm. Staff called on call nursing and was
directed to give the client a cool shower. When
the client awoke his temperature was 102.6 and
had a foul smell to his urine. Temperature went
down to 101.3 with shower and continued to rise
after shower and while getting dressed. Nursing
was called and directed to call EMS; Client #1
was picked up at 3:55 AM and on call nurse
would meet client at the hospital.

Interview with nursing on 11/10/21 verified there
had been no call from staff on 10/23/21 relative to
the multiple falls experienced by client #1. The
facility nurse further confirmed staff did not call
nursing until 10/24/21 due to concerns with client
#1's swollen area of the scrotum. Subsequent
interview with the facility nurse verified nursing
should have been called with the falls of client #1
on 10/23/21. Additional interview verified nursing
had provided no additional training relative to
timely reporting of a change in client health status
since 10/23/21 when staff failed to report multiple
falls of client #1.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60Z11

(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 340 | Continued From page 5 W 340

Facility ID: 922418 If continuation sheet Page 6 of 6

inspection_type: MHLCS Complaint


summary: Plan of Correction - MHLCS Complaint

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

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

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)

W 000° INITIAL COMMENTS

Intake # NC00183002, NC00183341
W331 NURSING SERVICES
CFR(s): 483.460(c)

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

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to provide nursing services in accordance
with the needs of 1 of 1 sampled clients (#1) with
not ensuring appropriate monitoring and staff
training after a medication change and a change
in client health status. The finding is:

Review of internal documents on 11/10/21
revealed an IRIS report completed 10/25/21
Review of the IRIS report revealed client #1 had
developed bruising, discoloration and swelling of
the scrotum area due to a fall. Continued review
of the IRIS report revealed client #1 to have a
diagnosis history of profound intellectual disability
with unspecified behaviors and emotional
disorders with onset in childhood.

Interview with the facility administrator on
11/10/21 revealed client #1 was currently ina
nursing facility due to the need for a higher level
of care after a recent hospitalization. Continued
interview with the administrator revealed client #1
was recently released from the hospital, after a
change in health status, with a permanent
catheter and currently required restraints to keep
the client from pulling the catheter out. Further
interview with the facility administrator revealed
due to the need for a permanent catheter and
client #1's need for restraints to prevent pulling
the catheter out the team had made the decision

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

PRINTED: 11/22/2021
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY
COMPLETED
Cc
B. WING ______._HH 11/10/2021
STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

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

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

woo *Cee attachment (4.2)

W 331

DHSR = Mental Health
DEC 21 2021

Lic. & Cert. Section

TITLE (x6) DATE

Sendiadiel fa

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: 060211 Facility ID: 922418 If continuation sheet Page 1 of 6

PRINTED: 11/22/2021
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: COMPLETED

A. BUILDING

c
346089 BWING 11/10/2021

NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE
SWANNANOA, NC 28778

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(xa) 1D 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, pate
DEFICIENCY)

W 331 Continued From page 1 W 331
| the clients’ needs could not be met internally and
client #1 would need a different level of care upon
hospital discharge.

Areview of incident reports for client #1 from
10/22 through 10/25/21 revealed the following:

On 10/22/21 Client #1 experienced a fall without
injury. Continued review of the 10/22/21 incident
report revealed nursing assessed the client on
10/22/21 regarding the fall.

On 10/23/21 (5:00 PM) client #1 was sitting on
the floor and staff assisted the client back to his
feet and client #1 continued to walk around.
Continued review of the 10/23/21 incident report
revealed client #1 continued to fall several times
over the next 30 to 40 minutes. Further review
revealed staff tried to put shoes on client #1
thinking the client was having a traction issue and
the client continued to fall. Subsequent review
revealed staff was able to get client #1 toa
recliner where the client sat waiting for his dinner
meal. Additional review of the 10/23/21 incident
report revealed staff contacted a supervisor at
5:30 PM although no notification of nursing was
documented.

On 10/24/21 (5:30 AM) While changing client #1
in bed, the client would not stand and it was
noticed his scrotum was purplish in color.
Continued review of the 10/24/21 incident report
revealed nursing was contacted and client #1 was
sent out to the local emergency room. Further
review revealed client #1 returned to the facility
around 2:45 PM after going out for medical
evaluation and had no new orders or diagnosis.

On 10/25/21 client #1 awoke at 2:05 AM and felt

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:D60211 Facility ID: 922418 If continuation sheet Page 2 of 6

BlueWest Opportunities —- Swannanoa

Plan of Correction

Complaint Survey 11/10/2021

W 331 Nursing Services

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

The Residential Program Administrator will conduct training with interdisciplinary team members
responsible for reviewing and responding to incidents. The training will detail agency protocols for
incident review and response, including timely training of staff regarding changes in client plans of care.

As well, BlueWest Opportunities nursing department will include in its procedures the notification to
staff of any medication changes and associated changes in support needs.

BlueWest Opportunities critical incident review committee will continue to meet weekly and review any
allegations and related inquiries/investigations for thoroughness, and, as well, incident reports will be
reviewed at least weekly by the Quality Assurance Manager; any followup thereby identified will be
conducted immediately by appropriate agency members in order to ensure continued compliance with
the expectation that the facility provides clients with nursing services in accordance with their needs.

Responsible persons: Residential Program Administrator, Quality Assurance Manager
Mechanism to ensure compliance: Regular review of incident reports

Frequency of mechanism: At least weekly

W 340 Nursing Services

Nursing services must include implementing with other members of the interdisciplinary team,
appropriate protective and preventive health measures that include, but are not limited to training
clients and staff as needed in appropriate health and hygiene methods.

The Residential Program Administrator will conduct training with management team members
responsible for responding to incidents. The training will detail agency protocols for incident response,
including timely reporting of changes in client condition to appropriate clinical team members.

BlueWest Opportunities critical incident review committee will continue to meet weekly and review any
allegations and related inquiries/investigations for thoroughness, and, as well, incident reports will be
reviewed at least weekly by the Quality Assurance Manager; any followup thereby identified will be
conducted immediately by appropriate agency members in order to ensure continued compliance with
the expectation that nursing services must include implementing with other members of the
interdisciplinary team, appropriate protective and preventive health measures that include, but are not
limited to training clients and staff as needed in appropriate health and hygiene methods.

Responsible persons: Residential Program Administrator, Quality Assurance Manager
Mechanism to ensure compliance: Regular review of incident reports

Frequency of mechanism: At least weekly

Derek Briscoe, Program Administrator
BlueWest Opportunities

43 College Place Suite 306

Asheville, NC 28803

12/3/2021
To the DHHS survey team:

On behalf of all the clients and the entire support team at BlueWest Opportunities, thank you for the
time and energy you spent with us on November 11, 2021 helping us to improve our services. Following,
you will find our plan to correct the issues cited during the survey. We look forward to the improved
outcomes you have helped us to identify.

We invite you back to our agency on January 9, 2022 to review corrections for both deficiencies cited.

Thank you again.

Sincerely,

JL fEA__—

Derek Briscoe


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

STATEMENT OF DEFICIENCIES

PRINTED: 09/10/2021
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
346089 B. WING 09/10/2021
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 9/10/2021 for all
previous deficiencies cited on 7/27/2021. 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:6WA612

Facility ID: 922418 If continuation sheet Page 1 of 1


raw_content:
PRINTED: 09/06/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

c
09/02/2021

A. BUILDING

34G089
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
91 POPLAR CIRCLE

SWANNANOA, NC 28778

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)
W 000 | INITIAL COMMENTS Ww 000

Acomplaint survey was conducted on 9/2/21.
Deficiencies were not cited as a result of the
complaint survey for Intake #NC00180804.

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: J3RH11 Facility ID: 922418 If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Annual and Complaint

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

STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION

346089 B. WING

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL,

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

W 000 | INITIAL COMMENTS

Complaint Intake#: NC00179341, NC00179668

CFR(s): 483.410(a)(1)

| The governing body must exercise general policy,
budget, and operating direction over the facility.

This STANDARD is not met as evidenced by:
Based on observation and interviews, the
governing body failed to exercise general policy
and operating direction over the facility by failing
to assure facility furniture was in good repair in
Beaucatcher. The finding is:

Observation conducted of the group home
furniture in the main day room of Beaucatcher on
7/27/21 revealed a recliner to slightly lean to the
left side. Continued observation revealed the foot
rest of the chair to protrude outward from the
chair and staff | to attempt to recline the chair
Upon staff I's attempt to recline the chair, the
| wooden leg came out from under the chair and
the foot rest was observed to be broken. Staff |,
then placed the chair back into an unreclined
position. Further observation revealed from 9:10
AM to 9:30 AM for client #11 to sit in the recliner
with the recliner leaning to the left side

Interview with client #19 revealed she enjoys
sitting in the recliner and had not done so for a
while as the recliner was broken and had been
broke for a while. Further interview confirmed
Client #6 also enjoys sitting in the recliner.
Interview with staff | on 7/27/21 revealed she had
previously requested repairs for the recliner and

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

wo00; See attached

W 104) GOVERNING BODY W 104

‘ ; Derek brisé Resdentia / fe Can,

(X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER A.BUILDING

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

DEFICIENCY)

DHSR - Mental Health
AUG 2.3 2021

Lic. & Cert. Section

TITLE

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

PRINTED: 08/09/2021
FORM APPROVED
OMB NO. 0938-0391

(x3) DATE SURVEY
COMPLETED

Cc
07/27/2021

(x8)

(6) DATE

trator &%: @:2/

Any deficiency statement ending with an asterisk (*) denotes @ 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:6WA611

Facility ID: 922418

If continuation sheet Page 1 of 28

BlueWest Opportunities —- Swannanoa
Plan of Correction

Survey 7/25/2021 to 7/26/2021

W 104 Governing body

The governing body failed to exercise general policy and operating direction over the facility by failing to
assure facility furniture was in good repair in Beaucatcher.

The chair noted to be broken during the survey has been removed from the group home. A replacement
chair has been ordered.

Staff will receive training regarding the facility's work order process, which will include training in
identifying environmental safety issues.

Assessments will be conducted at least monthly in each group home, and any followup identified will be
corrected immediately. These will be reviewed at least quarterly by the Quality Assurance Manager, and
any followup thereby identified will be conducted, in order to ensure continued compliance with the
expectation that the governing body must exercise general policy, budget, and operating direction over
the facility.

Responsible persons: Site Director
Mechanism to ensure compliance: Regular assessment

Frequency of mechanism: At least monthly in each group home

W 122 Client Protections

The facility failed to assure its policies and procedures that prohibit abuse and neglect were implemented
to prevent peer to peer abuse.

BlueWest Opportunities will revise its internal incident review process to include a cross-site review
component of allegations or inquiries into possible abuse or neglect. The review team will consist of
supervisory personnel NOT involved in the operations of the site in question nor the care of the clients
in question, and NOT in the same department.

Facility staff responsible for investigations into allegations of abuse or neglect will participate in training
from an outside agency relative to conducting investigations.

BlueWest Opportunities critical incident review committee will continue to meet weekly and review any
allegations and related inquiries/investigations for thoroughness, and any follow-up thereby identified
will be conducted by appropriate agency members in order to ensure continued compliance with the

expectation that the facility must develop and implement written policies and procedures that prohibit
mistreatment, neglect or abuse of the client.

Responsible persons: Residential Program Administrator, Quality Assurance Manager, CEO
Mechanism to ensure compliance: Critical incident reviews

Frequency of mechanism: Weekly

W 154 Staff treatment of clients
The facility failed to provide evidence an allegation of abuse was thoroughly investigated.

BlueWest Opportunities will revise its internal incident review process to include a cross-site review
component of allegations or inquiries into possibie abuse or neglect. The review team will consist of
supervisory personnel NOT involved in the operations of the site in question nor the care of the clients
in question, and NOT in the same department.

Facility staff responsible for investigations into allegations of abuse or neglect will participate in training
from an outside agency relative to conducting investigations.

BlueWest Opportunities critical incident review committee will continue to meet weekly and review any
allegations and related inquiries/investigations for thoroughness, and any follow-up thereby identified
will be conducted by appropriate agency members in order to ensure continued compliance with the
expectation that the facility must develop and implement written policies and procedures that prohibit
mistreatment, neglect or abuse of the client.

Responsible persons: Residential Program Administrator, Quality Assurance Manager, CEO
Mechanism to ensure compliance: Critical incident reviews

Frequency of mechanism: Weekly

W 186 Direct care staff
The facility failed to provide sufficient direct care staff to manage and supervise clients appropriately.

Staff working in Swannanoa will receive training on effective monitoring of clients in group homes using
a zone system, which will include how protocols change when optimal staff ratios are not available. The
training will provide solutions to common issues that arise with monitoring, giving staff the tools they
need to ensure that routine monitoring is continuous in all group homes. The training will include
information about client-specific monitoring needs as well.

An assessment has been developed which includes determining whether monitoring has been
continuous for the duration of the observation.

Assessments will be conducted at least monthly in each group home, and any followup identified will be
corrected immediately. These will be reviewed at least quarterly by the Quality Assurance Manager, and

any followup thereby identified will be conducted, in order to ensure continued compliance with the
expectation that the facility must provide sufficient direct care staff to manage and supervise clients in
accordance with their individual program plans.

Responsible Persons: Residential Program Administrator, Quality Assurance Manager
Mechanism to ensure compliance: Regular assessment

Frequency of Mechanism: At least monthly in each group home

W 249 Program implementation

The facility failed to ensure objectives and guidelines listed in the person centered plans were
implemented as prescribed

The IDT will revise client #16’s behavior support plan, and staff will receive training upon
implementation of the revised plan. The revision will include prevention strategies and interventions for
uncooperative behavior, and will continue the provision of line-of-sight supervision to prevent
inappropriate interpersonal interactions.

Staff will receive training on routine handwashing. The training will consist of information about the
importance of handwashing, about systems for ensuring handwashing is completed prior to meals in the
group homes, and about methods to increase client Participation/training in handwashing.

Assessments will be conducted at least monthly in each group home, and any followup identified will be
corrected immediately. These will be reviewed at least quarterly by the Quality Assurance Manager, and
any followup thereby identified will be conducted, in order to ensure continued compliance with the
expectation that 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.

Responsible Persons: QIDP, QIDP Assistant
Mechanism to ensure compliance: Regular interaction and mealtime assessments

Frequency of Mechanism: At least monthly in each group home

W 436 Space and equipment
The facility failed to ensure adaptive devices were kept clean.

Staff will receive training regarding the cleaning of adaptive equipment. The training will include
information about the importance of the cleanliness of the equipment, as well as on systems for
ensuring the cleanliness of the equipment is maintained. The staff will be provided with an updated
instruction guide for maintaining client-specific adaptive equipment in each group home.

An assessment has been developed which includes determining whether adaptive equipment is clean
and in good repair.

Assessments will be conducted at least monthly in each group home, and any followup identified will be
corrected immediately. These will be reviewed at least quarterly by the Quality Assurance Manager, and
any followup thereby identified will be conducted, in order to ensure continued compliance with the
expectation that 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.

Responsible Persons: PT/OT Assistant, Site Director
Mechanism to ensure compliance: Regular assessment

Frequency of Mechanism: At least monthly in each group home

W 473 Meal services
The facility failed to ensure food was served at the appropriate temperature.
Staff will receive training regarding serving food at the appropriate temperatures.

Assessments will be conducted at least monthly in each group home, and any followup identified will be
corrected immediately. These will be reviewed at least quarterly by the Quality Assurance Manager, and
any followup thereby identified will be conducted, in order to ensure continued compliance with the
expectation that the facility must serve food at the appropriate temperature

Responsible Person: Dietary Manager
Mechanism to ensure compliance: Regular assessment

Frequency of Mechanism: At least monthly

Derek Briscoe, Program Administrator
BlueWest Opportunities

43 College Place Suite 306

Asheville, NC 28803

8/16/2021
To the DHHS survey team:

On behalf of all the clients and the entire support team at BlueWest Opportunities, thank you for the
time and energy you spent with us on July 25-26" 2021 helping us to improve our services. Following,
you will find our plan to correct the issues cited during the survey. We look forward to the improved
outcomes you have helped us to identify.

We invite you back to our agency on September 10“ 2021 to review corrections for all deficiencies cited,
both conditional and standard level.

Thank you again.

Sincerely,

SEA ___

Derek Briscoe

inspection_type: MHLCS Annual and Complaint