summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 08/09/2021
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 07/27/2021

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 (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

Complaint Intake#: NC00179341, NC00179668
W 104 | GOVERNING BODY W 104
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 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: 6WA611 Facility ID: 922418 If continuation sheet Page 1 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(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

(8)
COMPLETION
DATE

W 104 | Continued From page 1

was assured the repairs were completed. Further
interview with staff J verified client #6 and #19
prefer to sit in the recliner while in the dayroom.
Additional interview with staff J revealed a work
order should be completed to address the need
for furniture repairs.

Interview with the clinical director on 7/27/21
revealed all furniture should be in good repair and
without safety concerns to clients in the home.
Continued interview with the clinical director
revealed furniture should also be arranged or
removed after an observation of a safety issue to
provide safety to the clients in the facility until
maintenance can conduct necessary repairs.
CLIENT PROTECTIONS

CFR(s): 483.420

W 122

The facility must ensure that specific client
protections requirements are met.

This CONDITION is not met as evidenced by:
The facility failed to: implement written policies
and procedures that prohibit mistreatment,
neglect and abuse of clients (W149) and failed to
provide evidence that all alleged violations were
thoroughly investigated (W154).

The cumulative effect of these systemic practices
resulted in the facility's failure to provide
statutorily mandated services of Client Protection
for it's clients.

STAFF TREATMENT OF CLIENTS

CFR(s): 483.420(d)(1)

W 149

The facility must develop and implement written

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 104

W 122

W 149

Facility ID: 922418 If continuation sheet Page 2 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

policies and procedures that prohibit
mistreatment, neglect or abuse of the client.

This STANDARD is not met as evidenced by:
Based on observation, record/document review
and interview, the facility failed to assure it's
policies and procedures that prohibit abuse and
neglect were implemented to prevent peer to peer
abuse for 1 of 6 sampled clients (#4). The finding
Is:

Review of internal facility documents on 7/26/21
revealed an incident report dated 7/14/21.
Review of the 7/14/21 incident report revealed
staff A had observed client #16 to exit and close
the bedroom door of clients #4 and #23, two
females that resided in the group home, after
client #16 had informed staff A he was going to
bed (10:20 PM). Continued review of
documentation from the 7/14/21 incident revealed
staff A to indicate abuse was suspected during
the incident.

Interview with the clinical director on 7/26/21
revealed he had interviewed staff A after the
7/14/21 incident and had confirmed staff A had
not observed any direct physical contact between
client #16 and client #4 or #23 during the 7/14/21
incident. Continued interview with the clinical
director revealed the incident was immediately
reported to the site supervisor and an observation
of client #4 after the incident revealed the client's
brief to be opened up and pulled down. Further
interview with the clinical director revealed a
nursing evaluation was conducted on client #4
and #23 on 7/15/21 to assess for sexual abuse.

Subsequent interview with the clinical director on

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 149 Continued From page 2 W 149

Facility ID: 922418 If continuation sheet Page 3 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

7/26/21 revealed an in-service training was
conducted with all staff that work with client #16
on 7/16/21 relative to the bedroom alarm for the
client. Interview with the clinical director verified
no additional protective measures had been
implemented with the 7/14/21 incident other than
a nursing evaluation for client #4 and #23, an
in-service regarding client #16's bedroom door
alarm and consideration of the clinical team as to
the appropriateness of keeping client #4 and #23
in the same home as #16. Additional interview
with the clinical director verified the facility had
not initiated a formal investigation regarding the
7/14/21 incident although the facility had
interviewed staff A and reviewed camera footage
in the group home from 7/14/21. The clinical
director further confirmed a current facility inquiry
had started 7/25/21 due to a report of information
that was different from the information reported in
the 7/14/21 incident by staff A.

Review of records for client #16 on 7/26/21
revealed a person centered plan (PCP) dated
5/9/21. Continued review of the PCP for client
#16 revealed a behavior support plan dated
9/24/20. Review of the current behavior plan for
client #16 revealed target behaviors of
non-compliance, intrusive attention seeking,
inappropriate contact, verbal aggression, PICA,
physical aggression, property destruction, AWOL,
verbally threatening self injurious behavior, self
injury, making untrue statements, inappropriate
sexual self stimulation, invading the privacy of
other persons bedrooms and taking inappropriate
foods. Additional record review for client #16
revealed a diagnosis history of mild intellectual
disability, pervasive developmental disorder,
bi-polar disorder and oppositional defiant
disorder.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 149 Continued From page 3 W 149

Facility ID: 922418 If continuation sheet Page 4 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

Interview with clinical director on 7/26/21, after
the initial interview, verified client #16 has had a
history of involvement in allegations regarding
sexual behavior towards other clients although no
allegation of sexual abuse had ever been
substantiated. The clinical director further
confirmed clients #4 and #23 would be moved, on
the current day, to another residence on the
facility site, outside the residence of client #16.

Observation in the group home on 7/26/21
verified client #4 and #23 had been moved to
another residence on the facility site.
Observation of client #4 and #23, at their
relocated residence in Sunset, revealed both
clients to be non-verbal and client #4 to ambulate
in a wheelchair with staff assistance.

Interview with staff A on 7/26/21 verified he had
observed client #16 to exit the bedroom and close
the door of client #4 and #23 on 7/14/21.
Continued interview with staff A revealed while he
did not observe direct physical contact of client
#16 with client #4 or #23 he was concerned with
what did happen. Further interview with staff A
verified he immediately reported the incident to
the site supervisor.

Interview with the site supervisor, staff B, on
7/26/21 revealed he was informed by staff A of
the incident on 7/14/21 involving client #16.
Continued interview with staff B revealed he
conducted an immediate observation of clients #4
and #23 with the report received by staff A and
observed the blanket for client #4 to be pulled
back, the brief of client #4 to be undone and the
brief to be folded down between the client's legs.
Subsequent interview with staff B revealed he

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 149 Continued From page 4 W 149

Facility ID: 922418 If continuation sheet Page 5 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

reported the observation to the clinical director.
Additional interview with staff B revealed the
observation of client #4 after the incident was not
consistent with the client's physical abilities to pull
back her own bed linens, undue her brief or fold it
down.

Interview with the clinical director and facility
administrator on 7/27/21 revealed, after a review
of camera footage during the survey process, that
client #16 had entered the bedroom of client #4
and #23 for approximately 8 minutes on 7/20/21
and it could not be determined what occurred
while client #16 was in the bedroom. Continued
interview revealed the clinical director and the
facility director to verify it had also been
discovered, with video review, that client #16 had
sexually abused client #4 on 7/23/21. Further
interview with administration staff verified client
#16 had sexually abused client #4 in the common
room of the group home with (2) staff on shift.
Subsequent interview with administration
confirmed the staff on shift were not supervising
clients as (1) staff was in the medication room
and the other staff had left the group home to
conduct medication administration in another
residence on the site.

Review on 7/27/21 of the facility's abuse and
neglect policy titled "Abuse, Neglect and
Exploitation" dated 7/1/2019 revealed all
individuals served by the organization are to be
protected from abuse, neglect, exploitation and
mistreatment. Continued review of the facility's
abuse and neglect policy revealed allegations of
abuse, neglect or exploitation are to be
investigated thoroughly.

Interview with administration staff verified they

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 149 Continued From page 5 W 149

Facility ID: 922418 If continuation sheet Page 6 of 28

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING
c

07/27/2021

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 149 Continued From page 6

had neglected to protect client #4 from peer to
peer abuse and failed to implement sufficient
safeguards after receiving information regarding
a possible incident of abuse on 7/14/21 that could
have prevented a substantiated finding of abuse
on 7/23/21. Subsequent interview with
administration staff verified client #16's
supervision guidelines would be increased to 1:1
as of the current survey date with additional
training for any staff providing supervision to the
client.

STAFF TREATMENT OF CLIENTS

CFR(s): 483.420(d)(3)

W 154

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

This STANDARD is not met as evidenced by:
Based on review of facility records and interview,
the facility failed to provide evidence an allegation
of abuse was thoroughly investigated for 1 of 6
sampled clients (#4). The finding is:

Review of internal facility documents on 7/26/21
revealed an incident report dated 7/14/21.
Review of the 7/14/21 incident report revealed
staff A had observed client #16 to close the
bedroom door of clients #4 and #23, two females
that resided in the group home, after client #16
had informed staff A he was going to bed (10:20
PM). Continued review of documentation from
the 7/14/21 incident revealed staff A to indicate
abuse was suspected during the incident.

Interview with the clinical director on 7/26/21
revealed he had interviewed staff A after the
7/14/21 incident and had confirmed staff A had

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 149

W 154

Facility ID: 922418 If continuation sheet Page 7 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

not observed any direct physical contact between
client #16 and client #4 or #23 during the 7/14/21
incident. Continued interview with the clinical
director revealed the incident was immediately
reported to the site supervisor and an observation
of client #4 after the incident revealed the client's
brief to be opened up and pulled down. Further
interview with the clinical director revealed a
nursing evaluation was conducted on client #4
and #23 on 7/15/21 to assess for sexual abuse.
Subsequent interview with the clinical director
revealed an in-service training was conducted on
7/16/21 with all staff that work with client #16
relative to the bedroom alarm for the client.

Interview with the clinical director on 7/26/21
verified no additional protective measures had
been implemented since 7/14/21 other than a
nursing evaluation for client #4 and #23, and
in-service regarding client #16's bedroom alarm.
Interview with the clinical director also revealed
the clinical team was reviewing the
appropriateness of keeping client #4 and #23 in
the same home as #16, while at the time of
interview, all clients resided together. Additional
interview with the clinical director verified the
facility had not initiated a formal investigation
regarding the 7/14/21 incident although the facility
had interviewed staff A and reviewed camera
footage in the group home from 7/14/21. The
clinical director further confirmed a current facility
inquiry had started 7/25/21 due to a report of
information that was different from the information
reported in the 7/14/21 incident by staff A.

Review of records for client #16 on 7/26/21
revealed a person centered plan (PCP) dated
5/9/21. Continued review of the PCP for client
#16 revealed a behavior support plan dated

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 154 | Continued From page 7 W 154

Facility ID: 922418 If continuation sheet Page 8 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

9/24/20. Review of the current behavior plan for
client #16 revealed target behaviors of
non-compliance, intrusive attention seeking,
inappropriate contact, verbal aggression, PICA,
physical aggression, property destruction, AWOL,
verbally threatening self injurious behavior, self
injury, making untrue statements, inappropriate
sexual self stimulation, invading the privacy of
other persons bedrooms and taking inappropriate
foods. Additional record review for client #16
revealed a diagnosis history of mild intellectual
disability, pervasive developmental disorder,
bi-polar disorder and oppositional defiant
disorder.

Interview with clinical director on 7/26/21, after
the initial interview, verified client #16 has had a
history of involvement in allegations regarding
sexual behavior towards other clients although no
allegation of sexual abuse had ever been
substantiated. The clinical director further
confirmed clients #4 and #23 would be moved on
the current day to another residence on the
facility site, outside the residence of client #16.

Observation in the group home on 7/26/21
verified client #4 and #23 had been moved to
another residence on the facility site.
Observation of client #4 and #23, at their
relocated residence in Sunset, revealed both
clients to be non-verbal and client #4 to ambulate
in a wheelchair with staff assistance.

Interview with staff A on 7/26/21 verified he had
observed client #16 to exit the bedroom and close
the bedroom door of client #4 and #23 on
7/14/21. Continued interview with staff A revealed
while he did not observe direct physical contact of
client #16 with client #4 or #23 he was concerned

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 154 | Continued From page 8 W 154

Facility ID: 922418 If continuation sheet Page 9 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

with what did happen. Further interview with staff
A verified he immediately reported the incident to
the site supervisor.

Interview with the site supervisor, staff B, on
7/26/21 revealed he was informed by staff A of
the incident on 7/14/21 involving client #16.
Continued interview with staff B revealed he
conducted an immediate observation of clients #4
and #23 with the report received by staff A and
observed the blanket for client #4 to be pulled
back, the brief of client #4 to be undone and the
brief to be folded down between the client's legs.
Subsequent interview with staff B revealed he
reported the observation immediately to the
clinical director. Additional interview with staff B
revealed the observation of client #4 after the
incident was not consistent with the client's
physical abilities to pull back her own bed linens,
undue her brief or fold it down.

Interview with the clinical director and facility
administrator on 7/27/21 revealed, after a review
of camera footage during the survey process, that
client #16 had entered the bedroom of client #4
and #23 for approximately 8 minutes on 7/20/21
and it could not be determined what occurred
while client #16 was in the bedroom. Continued
interview revealed the clinical director and the
facility administrator to verify it had also been
discovered, with video review during the survey
process, that client #16 had sexually abused
client #4 on 7/23/21. Further interview with
administration staff verified client #16 had
sexually abused client #4 in the common room of
the group home with (2) staff on shift.
Subsequent interview with administration
confirmed the staff on shift were not supervising
clients as (1) staff was in the medication room

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 154 | Continued From page 9 W 154

Facility ID: 922418 If continuation sheet Page 10 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(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

(8)
COMPLETION
DATE

W 154 | Continued From page 10

and the other staff had left the group home to
conduct medication administration in another
residence on the site.

Interview with administration staff verified they
had failed to protect client #4 from abuse and
failed to implement sufficient safeguards after
receiving information regarding a possible
incident of abuse on 7/14/21 that could have
prevented a substantiated finding of abuse on
7/23/21. Additional interview verified if a thorough
investigation had been conducted relative to the
7/14/21 incident, findings could have prevented
further incidents that occurred between client #16
and client #4.

DIRECT CARE STAFF

CFR(s): 483.430(d)(1-2)

W 186

The facility must provide sufficient direct care
staff to manage and supervise clients in
accordance with their individual program plans.

Direct care staff are defined as the present
on-duty staff calculated over all shifts in a 24-hour
period for each defined residential living unit.

This STANDARD is not met as evidenced by:
Based on interviews and record verification the
facility failed to provide sufficient direct care staff
to manage and supervise clients appropriately.

The finding is:

Interview on 7/27/21 with the clinical director and
facility director revealed, after a review of group
home camera video on 7/26/21 and 7/27/21 by
administration staff, it was discovered on 7/20/21
that client #16 had entered the bedroom of client

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 154

W 186

Facility ID: 922418 If continuation sheet Page 11 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

#4 and #23 for approximately 8 minutes.
Continued interview with administration revealed
it could not be determined what occurred on
7/20/21 while client #16 was in the bedroom of
client #4 and #23. Further interview revealed the
clinical director and the facility director to verify it
had also been discovered, with video review, that
client #16 had sexually abused client #4 on
7/23/21. Subsequent interview with
administration staff verified client #16 had
sexually abused client #4 in the common room of
the group home with (2) staff on shift. Interview
with administration additionally verified the staff
on shift were not supervising clients as (1) staff
was in the medication room and the other staff
had left the group home to conduct medication
administration in another residence on the site.

Review of records for client #16 on 7/26/21
revealed a person centered plan (PCP) dated
5/9/21. Continued review of the PCP for client
#16 revealed a behavior support plan dated
9/24/20. Review of the current behavior plan for
client #16 revealed target behaviors of
non-compliance, intrusive attention seeking,
inappropriate contact, verbal aggression, PICA,
physical aggression, property destruction, AWOL,
verbally threatening self injurious behavior, self
injury, making untrue statements, inappropriate
sexual self stimulation, invading the privacy of
other persons bedrooms and taking inappropriate
foods. Additional record review for client #16
revealed a diagnosis history of mild intellectual
disability, pervasive developmental disorder,
bi-polar disorder and oppositional defiant
disorder.

Additional interview with clinical director during
the 7/26-27/2021 survey verified client #16 had a

Event ID: 6WA611

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

(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 186 | Continued From page 11 W 186

Facility ID: 922418 If continuation sheet Page 12 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(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

(8)
COMPLETION
DATE

W 186 | Continued From page 12

history of involvement in allegations regarding
inappropriate sexual behavior towards other
clients although no allegation of sexual abuse
had ever been substantiated. The clinical director
and facility administrator further verified, with
interview on 7/27/21, the facility had failed to
provide appropriate supervision on 7/23/21 during
a time period that a substantiated incident of
sexual abuse had occurred between client #16
and client #4.

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 observations, review of records and
staff interviews, the facility failed to ensure
objectives and guidelines listed in the person
centered plans (PCP's) were implemented as
prescribed for 1 of 6 clients in Hawksbill (#16), 4
of 7 clients in Pisgah (#2, #7, #10 and #17) and 4
of 8 clients in Beaucatcher( #1,#5, #6 and #21).
The findings are:

A. The facility failed to ensure a behavior support
plan (BSP) was implemented as prescribed for
client #16. For example:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 186

W 249

Facility ID: 922418 If continuation sheet Page 13 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

1. The facility failed to implement a silent alarm
as prescribed for client #16.

Observation in the facility on 7/26/21 during
afternoon observations revealed an alarm to be
attached to the bedroom door of client #16
bedroom door. Continued observation in the
facility on 7/27/21 at 6:50 AM revealed client #16
to be in his bedroom with the door closed. Further
observation revealed client #16 to exit his
bedroom and walk the hallway of the facility.
Subsequent observation throughout the morning
observation period revealed the alarm control box
to client #16's door alarm to sit on a table in the
common area, unattended by staff until
observations ended at 9:15 AM.

Review of records for client #16 on 7/27/21
revealed a PCP dated 5/9/21 that reflected a
diagnosis history to include Mild Intellectual
Disability, Pervasive Developmental Disorder and
Bi-polar Disorder. Review of client #16's PCP
revealed a BSP dated 7/14/20. Review of the
current BSP for client #16 revealed target
behaviors of noncompliance, intrusive attention
seeking behavior, inappropriate contact (spitting,
touching people in private-sexual areas of the
body; possibly escalating to aggressive grabbing,
pulling or inappropriate "horse play"), verbal
aggression, pica, physical aggression, property
destruction, AWOL, verbally threatening
self-injury, self-injury, taking items inappropriately
(stealing), making untrue statements,
inappropriate sexual self stimulation, and
invading the privacy of other persons room (going
into the the bedroom of another client without
permission or approval).

Continued review of client #16's BSP revealed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 13 W 249

Facility ID: 922418 If continuation sheet Page 14 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

prevention strategies that include: a silent alarm
on the exits from his bedroom during team
designated times due to client #16 leaving his
room at night on second and third shift and going
into the bedroom of others. Further review of
guidelines relative to the silent alarm for client
#16 revealed when staff are aware the alarm is
activated they will observe and monitor the client
to ensure he does not enter the room of another
home resident.

Review on 7/27/21 of internal training revealed an
in-service training with staff on 7/16/21 specific to
client #16's room alarm. Review of the 7/16/21
training revealed in the event client #16 is in his
room, staff must have his "buzzer" (alarm) on
their person at all times; when the buzzer vibrates
this means that staff must go and check on client
#16 and see what he is doing immediately. The
charger for the buzzer is in the Hawksbill front
office, put it in there if not in use.

Interview with staff A on 7/26/21 revealed the
silent alarm for client #16 is used at night only
after the client goes to bed. Continued interview
with staff A revealed after client #16 goes to bed,
staff use the alarm control box to monitor client
#16 by keeping the control box on the staff and
monitoring the box for any vibration that would
indicate the client has opened his bedroom door.
It should be noted this surveyor had staff A to set
off the alarm to ensure working order of the
control box. Further interview with staff A
revealed the alarm control box is kept in a locked
area when not in use as client #16 is capable of
accessing the alarm box and tampering with the
controls.

Interview with the clinical director on 7/27/21

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 14 W 249

Facility ID: 922418 If continuation sheet Page 15 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

revealed the alarm control box should not have
been sitting on a table unattended in the common
area of the group home during morning
observations of survey of 7/27/21. Continued
interview with facility clinical director verified
guidelines regarding the silent alarm for client #16
should be more specific than to be used “during
team designated times".

2. The facility failed to implement supervision as
prescribed for client #16. For example:

Interview on 7/27/21 with the clinical director and
facility director revealed, after a review of group
home camera video on 7/26/21 and 7/27/21 by
administration staff, it was discovered on 7/20/21
that client #16 had entered the bedroom of client
#4 and #23 for approximately 8 minutes.
Continued interview with administration revealed
it could not be determined what occurred on
7/20/21 while client #16 was in the bedroom of
client #4 and #23. Further interview revealed the
clinical director and the facility director to verify it
had also been discovered, with video review, that
client #16 had sexually abused client #4 on
7/23/21. Subsequent interview with
administration staff verified client #16 had
sexually abused client #4 in the common room of
the group home with (2) staff on shift. Interview
with administration additionally verified the staff
on shift were not supervising clients as (1) staff
was in the medication room and the other staff
had left the group home to conduct medication
administration in another residence on the site.

Review of records for client #16 on 7/26/21
revealed a person centered plan (PCP) dated
5/9/21. Continued review of the PCP for client
#16 revealed a behavior support plan dated

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 15 W 249

Facility ID: 922418 If continuation sheet Page 16 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

9/24/20. Review of the current behavior plan for
client #16 revealed target behaviors of
non-compliance, intrusive attention seeking,
inappropriate contact, verbal aggression, PICA,
physical aggression, property destruction, AWOL,
verbally threatening self injurious behavior, self
injury, making untrue statements, inappropriate
sexual self stimulation, invading the privacy of
other persons bedrooms and taking inappropriate
foods. Additional record review for client #16
revealed a diagnosis history of mild intellectual
disability, pervasive developmental disorder,
bi-polar disorder and oppositional defiant
disorder.

Additional interview with clinical director during
the 7/26-27/2021 survey verified client #16 had a
history of involvement in allegations regarding
inappropriate sexual behavior towards other
clients and needed close supervision although no
allegation of sexual abuse had ever been
substantiated. The clinical director and facility
administrator further verified, with interview on
7/27/21, client #16 needs eyesight supervision
and the facility had failed to provide appropriate
supervision which had resulted in a substantiated
incident of sexual abuse between client #16 and
client #4.

3. The facility failed to address non-compliance
behaviors as prescribed for client #16.

Observation in Hawksbill, during survey
observations on 7/26/21 revealed client #16 to be
dressed in a pair of shorts and a t-shirt.
Continued observation on 7/27/21 during morning
observations revealed client #16 to exit his room
wearing the same clothing as observed on
7/26/21. Further observation throughout the

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

Event ID: 6WA611

(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 16 W 249

Facility ID: 922418 If continuation sheet Page 17 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

7/26-27/21 survey revealed client #16 to have a
set of clothes ,folded on the floor, outside his
bedroom door.

Review of records for client #16 on 7/26/21
revealed a person centered plan (PCP) dated
5/9/21. Continued record review for client #16
revealed a diagnosis history of mild intellectual
disability, pervasive developmental disorder,
bi-polar disorder and oppositional defiant
disorder. Review of the PCP for client #16
revealed a behavior support plan (BSP) dated
9/24/20. Review of the current behavior plan for
client #16 revealed target behaviors of
non-compliance, intrusive attention seeking,
inappropriate contact, verbal aggression, PICA,
physical aggression, property destruction, AWOL,
verbally threatening self injurious behavior, self
injury, making untrue statements, inappropriate
sexual self stimulation, invading the privacy of
other persons bedrooms and taking inappropriate
foods.

Subsequent review of the BSP for client #16
revealed non-compliance behaviors to include
refusing to cooperate with activities necessary for
his health, hygiene or habilitation and refusing to
follow or participate in his schedule of activities.
A review of data related to client #16's hygiene
revealed (3) days of data for 4/2021 with no data
for shower, (3) days of data for 5/2021 with no
data for shower and (13) days of data collection
for 7/2021. Data collection for 6/2021 was not
provided to the surveyor.

Additional review of the BSP for client #16
revealed prevention strategies for
non-compliance to include: A) Ask once, if client
#16 refuses walk away and go reinforce someone

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 17 W 249

Facility ID: 922418 If continuation sheet Page 18 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

else for cooperating with the same or similar task.
B) If necessary, ask again after a few minutes
and help him remember what reinforcers he gets
for getting his jobs done; remind him he earns
outings for being cooperative. C) If after two
prompts he still does not cooperate then wait
about 5-10 minutes then try again or have
another staff to try again. D) Notify the supervisor
if after 1 hour client #16 cannot be encouraged to
complete any necessary habilitation activities (self
care activities such as bathing, chores, goal
programs, etc).

Interview with staff C on 7/27/21 revealed client
#16 has non-compliance behaviors and should
have taken a shower the evening of 7/26 and
refused. Continued interview with staff C
revealed client #16's clothing in the hallway
outside his bedroom was in the hallway for the
client to either put away or use when he showers.
Interview with the clinical director on 7/27/21
revealed client #16 takes showers regularly and
all staff should support the client with prescribed
interventions of the clients BSP. Continued
interview with the clinical director verified staff
need additional training relative to supporting
client #16 with hygiene tasks.

B. The team failed to implement handwashing
objectives for 4 of 7 clients (#2, #7, #10, and #17)
in Pisgah. For example:

1. The team failed to implement handwashing for
client #2.

Surveyor arrived at the group home on 7/27/21 at
6:50 AM. Observation in the group home at 7:50
AM revealed client #2 to participate in a family
style breakfast meal. At no time during the
surveyor's observation of client #2 prior to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 18 W 249

Facility ID: 922418 If continuation sheet Page 19 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

breakfast did the client wash his hands or receive
a prompt from staff to wash his hands.

Review of client #2's record revealed a PCP
dated 6/14/21. Continued review of client #2's
PCP revealed a handwashing objective with an
implementation date of 8/20/20. Further review
revealed client #2 will wash his hands
independently 80% of the time for 3 consecutive
review periods.

2. The team failed to implement handwashing for
client #7.

Observation in the group home at 7:50 AM
revealed client #7 to participate in a family style
breakfast meal. At no time during the surveyor's
observation of client #7 prior to breakfast did the
client wash her hands or receive a prompt from
staff to wash her hands.

Review of client #7's record revealed a PCP
dated 8/11/20. Continued review of client #7's
PCP revealed a handwashing objective with an
implementation date of 5/19/20. Further review
revealed client #7 will wash her right hand with a
verbal prompt 70% of the time for 3 consecutive
review periods.

3. The team failed to implement handwashing for
client #10.

Observation in the group home at 7:50 AM
revealed client #10 to participate in a family style
breakfast meal. At no time during the surveyor's
observation of client #10 prior to breakfast did the
client wash her hands or receive a prompt from
staff to wash her hands.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 19 W 249

Facility ID: 922418 If continuation sheet Page 20 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

Review of client #10's record revealed a PCP
dated 11/16/20. Continued review of her PCP
revealed a handwashing objective with an
implementation date of 5/26/21. Further review
revealed the client will wash her hands with a
gestural prompt 70% of the time for 3 consecutive
review periods.

4. The team failed to implement handwashing for
client #17.

Observation in the group home at 7:50 AM
revealed client #17 to participate in a family style
breakfast meal. At no time during the surveyor's
observation of client #17 prior to breakfast did
she wash her hands or receive a prompt from
staff to wash her hands.

Review of client #17's record revealed a PCP
dated 11/16/20. Continued review of her PCP
revealed a handwashing objective with an
implementation date of 8/18/20. Further review
revealed the client will wash her hands with a
partial physical prompt 80% of the time for 3
consecutive review periods.

Interview with the clinical director on 7/27/21
confirmed all client's should be prompted to wash
their hands prior to meal participation. Continued
interview with the clinical director verified all
program objectives should be trained at every
opportunity and implemented as prescribed.

C. The team failed to implement handwashing
objectives for 4 of 8 clients (#1, #5, #6, and #22)
in Beaucatcher. For example:

Observation in the group home on 7/26/21 from
4:15 PM - 6:30 PM revealed all clients to
participate in leisure activities, snack time, the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 20 W 249

Facility ID: 922418 If continuation sheet Page 21 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

dinner meal, clean up tasks, and to take dishes to
the kitchen after the meal. At no time during
observations were clients prompted to wash their
hands.

Observation in the group home on 7/27/21 from
6:50 AM - 9:30 AM revealed all clients to get
dressed, to participate in the breakfast meal, to
take dishes to the kitchen, to participate in
medication administration and to leave the group
home for thier vocational setting. At no time
during observations were clients prompted to
wash their hands.

1. Review of client #1's record on 7/27/21
revealed a PCP dated 4/29/21. Continued review
of client #1's PCP revealed a handwashing
objective. Further review revealed client #1 will
wash her hands thoroughly with gestural prompts
80% of the time for 3 consecutive review periods.

2. Review of client #5's record on 7/27/21
revealed a PCP dated 8/17/20. Continued review
of client #5's PCP revealed a handwashing
objective. Further review revealed client #5 will
wash his hands thoroughly with gestural prompts
80% of the time for 3 consecutive review periods.

3. Review of client #6's record on 7/27/21
revealed a PCP dated 9/23/20. Continued review
of client #6's PCP revealed a handwashing
objective. Further review revealed client #6 will
wash her hands with gestural prompts 80% of the
time for 3 consecutive review periods.

4. Review of client #22's record on 7/27/21
revealed a PCP dated 7/22/20. Continued review
of client #22's PCP revealed a handwashing
objective. Further review revealed client #22 will

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 21 W 249

Facility ID: 922418 If continuation sheet Page 22 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(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

(8)
COMPLETION
DATE

W 249 | Continued From page 22

wash her hands with verbal prompts 80% of the
time for 3 consecutive review periods.

Interview with the clinical director on 7/27/21
revealed all handwashing objectives should be
implemented as prescribed and all clients should
be encouraged to wash their hands throughout
activity transitions. Continued interview with the
clinical director confirmed all clients should be
prompted to wash their hands before meals.
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 observations, review of records and
staff interviews, the facility failed to ensure
adaptive devices were kept clean for 3 of 6 clients
in Hawksbill (#3, #9, and #15) and 2 of 8 clients
in Beaucatcher( #6 and #14 ). The findings are:

A. The facility failed to ensure adaptive
equipment was clean for 4 of 6 clients in
Hawksbill. For example:

1. The facility failed to ensure adaptive
equipment relative to a face shield was clean for
client #3.

Observation in the facility during the 7/26-27

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 249

W 436

Facility ID: 922418 If continuation sheet Page 23 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

survey observations revealed client #3 to
ambulate with a helmet. Observation of client
#3's helmet revealed a face shield to be attached
that covered the clients full facial area.
Continued observation throughout the 7/26-27/21
survey revealed the face shield of client #3 to
appear dirty with accumulated debris on the
inside of the shield.

Review of records for client #3 on 7/26-27/21
revealed a person-centered plan (PCP) dated
6/1/21. Review of the PCP for client #3 revealed
adaptive equipment to include a helmet.
Continued review of adaptive equipment for client
#3 revealed a physical therapy note to indicate
the client's helmet includes a face shield to
prevent facial injury.

Interview with the clinical director on 7/27/21
revealed all adaptive equipment should be kept
clean for all clients. Continued interview with the
clinical director revealed staff on third shift are
responsible for cleaning adaptive equipment
while all staff should be monitoring adaptive
devices to ensure cleanliness.

2. The facility failed to ensure adaptive
equipment relative to a wheelchair and gait belt
were clean for client #9.

Observation in the facility during the 7/26-27
survey observations revealed client #9 to
ambulate in a wheelchair with a gait belt around
the clients waist. Observation of client #9's
wheelchair lap belt revealed dried food and debris
to be accumulated across the belt. Continued
observation throughout the 7/26-27/21 survey
revealed the gait belt that client #9 was observed
to wear also appeared to have dried debris and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 23 W 436

Facility ID: 922418 If continuation sheet Page 24 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

food stains along the front of the belt.

Review of records for client #9 on 7/27/21
revealed a person-centered plan (PCP) dated
12/1/20. Review of the PCP for client #9 revealed
adaptive equipment to include a wheelchair and
large padded gait belt.

Interview with the clinical director on 7/27/21
revealed all adaptive equipment should be kept
clean for all clients. Continued interview with the
clinical director revealed staff on third shift are
responsible for cleaning adaptive equipment
while all staff should be monitoring adaptive
devices to ensure cleanliness.

3. The facility failed to ensure adaptive
equipment relative to a wheelchair was clean for
client #15.

Observation in the facility during the 7/26-27
survey observations revealed client #15 to
ambulate in a wheelchair. Observation of client
#15's wheelchair lap belt revealed dried food and
debris to be accumulated across the belt.

Review of records for client #15 on 7/27/21
revealed a person-centered plan (PCP) dated
10/1/20. Review of the PCP for client #15
revealed adaptive equipment to include a
wheelchair.

Interview with the clinical director on 7/27/21
verified client #15 had a new wheelchair on order
due to multiple wear and tear concerns with the
client's current wheelchair. Continued interview
with the clinical director revealed all adaptive
equipment should be kept clean for all clients.
Further interview with the clinical director

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 24 W 436

Facility ID: 922418 If continuation sheet Page 25 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

revealed staff on third shift are responsible for
cleaning adaptive equipment while all staff should
be monitoring adaptive devices to ensure
equipment is clean.

B. The facility failed to ensure adaptive
equipment was clean for 2 of 8 clients in
Beaucatcher: For example:

1. The facility failed to ensure adaptive equipment
relative to a wheelchair was clean for client #6.

Observation in the facility during the 7/26/21 and
7/27/21 survey observations revealed client #6 to
ambulate in a wheelchair. Observation of client
#6's wheelchair revealed dried food and debris to
be accumulated beneath the seat cushion and on
both sides between the wheelchair frame and
wheels.

Review of records for client #6 on 7/27/21
revealed a person-centered plan (PCP) dated
9/23/20. Review of the PCP for client #6 revealed
adaptive equipment to include a wheelchair.

Interview with the clinical director on 7/27/21
revealed all adaptive equipment should be kept
clean for all clients. Further interview with the
clinical director revealed staff on third shift are
responsible for cleaning adaptive equipment
while all staff should be monitoring adaptive
devices to ensure equipment is clean.

2. The facility failed to ensure adaptive equipment
relative to a helmet strap was clean for client #14.

Observation in the facility during the 7/26/21 and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 25 W 436

Facility ID: 922418 If continuation sheet Page 26 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(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

(8)
COMPLETION
DATE

W 436 | Continued From page 26

7/27/21 survey observations revealed client #14
to ambulate throughout the home wearing a
helmet. Observation of client #6's helmet strap
revealed dried food and debris to be accumulated
across the strap.

Review of records for client #6 on 7/27/21
revealed a person-centered plan (PCP) dated
12/11/20. Review of the PCP for client #14
revealed adaptive equipment to include a helmet.

Interview with the clinical director on 7/27/21
revealed all adaptive equipment should be kept
clean for all clients. Further interview with the
clinical director revealed staff on third shift are
responsible for cleaning adaptive equipment
while all staff should be monitoring adaptive
devices to ensure equipment is clean.

MEAL SERVICES

CFR(s): 483.480(b)(2)(ii)

W 473

Food must be served at appropriate temperature.

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility
failed to ensure food was served at the
appropriate temperature for 8 of 8 clients (#1, #5,
#6, #11, #14, #18, #19, and #22) in Beaucatcher.
The finding is:

Observation in the group home on 7/27/21 at 7:10
AM revealed staff | to place breakfast items on
the table to include waffles, juice and milk.
Continued observations at 7:30 AM revealed
clients (#1, #5, #6, #11, #14, #18, #19 and #22) to
be seated at the dining table.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

W 436

W 473

Facility ID: 922418 If continuation sheet Page 27 of 28

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

(X3) DATE SURVEY
COMPLETED

c
07/27/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

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

Further observation at 7:45 AM revealed staff | to
assist client #11, #14, #19 and #22 to fix their
plates and to pour milk from the pitcher into a cup
for each client. Observation at 7:45 AM revealed
the milk to sit out of the refrigerator for over 30
minutes. Subsequent observation at 7:50 AM
revealed all clients to engage in eating and
drinking breakfast items. Additional observation
at 8:15 AM revealed staff | to return the drink
items to the kitchen, including the milk which was
placed back into the refrigerator.

Interview with the facility dietician on 7/27/21 at
8:15 AM revealed that milk should not sit outside
of refrigeration for more than 15 minutes.
Continued interview revealed food temperature
should be checked with a thermometer to ensure
appropriate serving temperature after food has
been on the table an extended period of time.

Interview with the clinical director on 7/27/21
confirmed milk should not have been allowed to
remain outside of refrigeration for more than 15
minutes. The clinical director further confirmed
the milk remaining in the pitcher after the
breakfast meal should have been discarded.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6WA611

(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 473 | Continued From page 27 W 473

Facility ID: 922418 If continuation sheet Page 28 of 28


state: NC

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 03/30/2021
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
03/29/2021

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

A complaint survey was conducted on 3/29/21.
Deficiencies were not cited as a result of the
complaint survey for Intake #NC00175751.

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: IKPK11 Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 11/29/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
34G089 B.WING 11/21/2019
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 11/21/19 for all
previous deficiencies cited on 9/11/19. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

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

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2412 Facility ID: 922418 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up


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

PRINTED: 11/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
34G089 B. WING 11/21/2019
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 (%5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
No deficiencies were cited as a result of a
complaint survey conducted on 11/21/19 for
Intakes #NC157616, NC157670, NC157844,
NC158234.
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:T1F211 Facility ID: 922418 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Annual

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

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

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

(X3) DATE SURVEY
COMPLETED

B. WING

34G089 09/11/2019

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 189 | STAFF TRAINING PROGRAM W 189

CFR(s): 483.430(e)(1)

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

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure staff were
sufficiently trained relative to client positioning at
meals for 1 of 2 sampled clients (#27) in
Beaucatcher. The finding is:

Observations in the group home on 9/10/19 at
6:25 PM revealed client #27 to participate in the
supper meal that included beef casserole, refried
beans and fruit. Continued observation of client
#27 at the supper meal revealed the client to sit in
a wheelchair at the table, to feed herself with staff
assistance when needed and to utilize a swivel
spoon utensil. Continued observation revealed
client #1 to have excessive food spillage while
self feeding, dropping food into both the
wheelchair and the client's lap.

Review of records for client #1 on 9/11/19
revealed a an occupational therapy (OT)
evaluation dated 7/23/19. Review of the OT
evaluation revealed client #1 to have a pureed
diet with thin liquids. Further review of the OT
evaluation revealed client #1 to have a thoracic
cushion in her dining chair due to a diagnosis of
severe kyphoscoliosis. The 7/2019 OT
evaluation further reflected the recommendation
at meals that staff need to ensure client #1 is
transferred from her wheelchair to the wooden
chair for optimal positioning to feed herself

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:0Q2411 Facility ID: 922418 If continuation sheet Page 1 of 10

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

(X4) ID
PREFIX
TAG

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
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)

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

ID
PREFIX
TAG

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

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)

(X3) DATE SURVEY
COMPLETED

09/11/2019

(x5)
COMPLETION
DATE

W 189

W 227

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

Continued From page 1
successfully.

Interview with the qualified intellectual disabilities
professional (QIDP) on 9/11/19 revealed client #1
should have been transferred to the wooden
dining chair that is used for client #27 at all meals
to support proper positioning of the client while
self feeding.

INDIVIDUAL PROGRAM PLAN

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 observation, review of records and
interview, the team failed to ensure the individual
service plan (ISP) for 1 of 4 sampled clients (#1)
in Beaucatcher included objective training to
address needs relative to behavior management.
The finding is:

Observation in the group home on 9/11/19 at 8:25
AM revealed client #5 to walk down the hallway of
the group home after the breakfast meal and
attempt to hold onto this surveyor by the pants
and to grab and pull this surveyor's hand.
Continued observation from 8:30 AM until 8:45
AM revealed staff C and Y to observe client #1 to
follow this surveyor around the facility, attempting
to grab this surveyor by the pant leg and hand
while providing no redirection of client #1.
Observation further revealed client #1 to walk
close to client #17 in the facility hallway and client

Event ID:0Q2411

W 189

W 227

Facility ID: 922418

If continuation sheet Page 2 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X4) ID
PREFIX
TAG

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

ID
PREFIX
TAG

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

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

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

(x5)
COMPLETION
DATE

DEFICIENCY)

W 227 | Continued From page 2

#17 to state "No, get away from me".
Observation at 8:48 AM revealed Staff Y to
prompt client #1 to a morning routine activity of
changing clothes to which the client complied.

Review of records for client #1 on 9/11/19
revealed an ISP dated 12/4/19. Review of the
ISP revealed current training objectives to
address daily living skills and hygiene. Further
review of the ISP revealed no behavior support
guidelines, objectives or interventions to address
observed behaviors of pulling on others, following

W 249

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

or invading tl

Interview witl
intellectual d

he personal space of others.

h the clinical director and qualified
isabilities professional (QIDP) on

9/11/19 verified client #1 did not have a behavior
support plan. Further interview with the clinical
director and QIDP confirmed client #1 has a
history of behavior that included pulling on staff
hat is usually related to communication.
Additional interview verified client #1 will invade
he personal space of others in an effort to get
attention. Interview with the clinical director and
QIDP confirmed client #1 could be benefit from
taining to address identified needs of pulling
behavior and invading the personal space of
others.
PROGRAM IMPLEMENTATION
CFR(s): 483.440(d)(1)

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

Event ID:0Q2411

W 227

W 249

Facility ID: 922418

If continuation sheet Page 3 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

91 POPLAR CIRCLE

STREET ADDRESS, CITY, STATE, ZIP CODE

SWANNANOA, NC 28778

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

plan.

This STANDARD is not met as evidenced by:
Based on observations, review of records and
staff interviews, the facility failed to ensure
objectives and guidelines listed in the individual
service plans (ISP's) were implemented as
prescribed for 3 of 3 sampled clients in Sunset
(#9, #25 and #29) and 1 of 2 sampled clients in
Beaucatcher (#27). The findings are:

A. The facility failed to ensure a meal preparation
objective was implemented as prescribed for
client #9.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Observations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients.
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table.
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean
salad, and mashed potatoes.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

(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 249 | Continued From page 3 W 249

Facility ID: 922418

If continuation sheet Page 4 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

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

Review of the record for client #9 on 9/11/19
revealed an ISP dated 3/1/19 which included a
nutrition section, which indicated the client has a
regular, pureed diet. Further review of the ISP
revealed an objective implemented 11/6/18 for
client #9 to initiate pushing down on a switch to
puree meal items 75% of the time for three
consecutive months.

Interview with the qualified intellectual disabilities
professional (QIDP) on 9/11/19 confirmed the
food processing objective was current and
confirmed the objective should be trained at all
opportunities.

B. The facility failed to ensure a meal preparation
guideline was implemented as prescribed for
client #25.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Observations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients.
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table.
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

(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 249 | Continued From page 4 W 249

Facility ID: 922418

If continuation sheet Page 5 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

91 POPLAR CIRCLE

STREET ADDRESS, CITY, STATE, ZIP CODE

SWANNANOA, NC 28778

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

salad, and mashed potatoes.

Review of the record for client #25 on 9/11/19
revealed an ISP dated 11/11/18 which included a
nutrition section, which indicated the client has a
regular pureed diet. Further review of the ISP
revealed a current meal preparation guideline for
the client to puree her food items.

Interview with the QIDP on 9/11/19 confirmed the
food processing guideline was current and
confirmed the guideline should be followed at all
opportunities.

C. The facility failed to ensure a meal preparation
guideline was implemented as prescribed for
client #29.

Observations in Sunset on 9/10/19 at 4:35 PM
revealed clients #9, #25 and #29 to be seated at
the dining table for snack. Further observations
at that time revealed staff A in the kitchen
operating a food processor to puree cookies
without the assistance of any clients. Continued
observations at 4:45 PM revealed clients #9, #25
and #29 eating the pureed cookies for the snack
meal.

Observations on 9/10/19 at 5:27 PM revealed
staff V in the kitchen processing dinner food
items without assistance from any clients.
Further observations at 6:00 PM revealed staff Z
processing dinner food items without the
assistance of clients and at that time, clients #9,
#25 and #29 were sitting at the dining table.
Continued observations at 6:10 PM revealed
clients #9, #25 and #29 eating pureed dinner
items consisting of beef and re-fried beans, bean
salad, and mashed potatoes.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

(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 249 | Continued From page 5 W 249

Facility ID: 922418

If continuation sheet Page 6 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

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

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

Review of the record for client #29 on 9/11/19
revealed an ISP dated 4/11/19 which included a
nutrition section, which indicated the client has a
1200 calorie, low fat, pureed diet. Further review
of the ISP revealed a current meal preparation
guideline for the client to push the button on the
food processor to help puree her food.

Interview with the QIDP on 9/11/19 confirmed the
food processing guideline was current and
confirmed the guideline should be followed at all
opportunities.

D. The facility failed to ensure meal guidelines
were implemented as prescribed for client #27.

Observations in the group home on 9/10/19 at
6:25 PM revealed client #27 to participate in the
supper meal that included beef casserole, refried
beans and fruit. Continued observation of client
#27 at the supper meal revealed the client to sit in
a wheelchair at the table, to self feed with staff
assistance when needed and to utilize a swivel
spoon utensil. Continued observation revealed
client #1 to have excessive food spillage while
self feeding, dropping food into the wheelchair
and onto the client's lap. At no time during
observation of the supper meal was it observed
for staff to offer client #27 additional food to
replace spillage.

Observation in the group home on 9/11/19 of
client #27 during the breakfast meal revealed the
client to sit in a wooden chair, to eat her complete
breakfast meal with hand over hand staff
assistance and to utilize a swivel spoon utensil. It
was not observed during the breakfast meal for
client #27 to have the opportunity to self feed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

(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 249 | Continued From page 6 W 249

Facility ID: 922418

If continuation sheet Page 7 of 10

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

(X4) ID
PREFIX
TAG

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
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)

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

ID
PREFIX
TAG

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

(x3)

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)

COMPLETED

DATE SURVEY

09/11/2019

(x5)
COMPLETION
DATE

W 249

W 436

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

Continued From page 7
during any part of the meal.

Review of records for client #27 on 9/11/19
revealed mealtime guidelines dated 8/28/19.
Review of the 8/28/19 meal guidelines revealed a
schedule frequency for all snacks and meals.
Continued review of meal guidelines for client #27
revealed a teaching method that indicated 1) Staff
will encourage client #27 to feed herself as much
as possible. 2) Staff may assist the client in
feeding herself by gently putting pressure on the
underside of her dominant elbow (to reduce
severity of tremors). 3) If the client spills any of
her food, please replace the food spilled with
more food. 4) After client #27 has been eating 30
minutes, staff may then provide the client with
hand over hand assistance to finish her meal.

Interview with the QIDP on 9/11/19 verified the
meal guidelines for client #27 remain current.
Continued interview with the QIDP revealed
additional food should have been offered to the
client to address spillage during meals. The
QIDP further confirmed staff should not begin
hand over hand assisting client #27 with eating
unless the client has been eating 30 minutes and
is continuing to take a long time to finish her
meal.

SPACE AND EQUIPMENT

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

The facility must furnish, maintain in good repair,
and teach clients to use and to make informed
hoices 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.

Q

Event ID:0Q2411

W 249

W 436

Facility ID: 922418

If continuation sheet Page 8 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

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

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility
failed to maintain in good repair, a wheelchair for
1 of 2 sampled clients (#2) in Pisgah. The finding

is:

Observation in the group home 9/10/19 revealed
client #2 sitting in a wheelchair at the dinner table.
Observation of client #2's wheelchair revealed a
spoke with a sharp edge to protrude outward
from the client's tire . Further observation
revealed client #2 conversing with the qualified
intellectual disabilities professional (QIDP)
pointing at the spoke stating it needed to be
repaired. The QIDP was observed to respond to
client #2 during conversation with "| know" and
further explained a special tool was needed to
complete the repair.

Observation in the group home on 9/11/19 at 9:05
AM revealed while loading on the van, client #2
informed and pointed out to the internal physical

thera
needed

revealed

#2 wi

contact

take a lo

Interv

revealed

py staff that the spoke on her wheelchair
0 be repaired. Further observation
the internal PT staff to respond to client

h acknowledgement and the need to

he wheelchair company to come out and
ok at the wheelchair.

iew with the internal PT staff on 9/11/19

the staff to be responsible for repairs

(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 436 | Continued From page 8 W 436

and maintenance of adaptive equipment.
Interview with group home staff on 9/11/19

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

revealed

of repair

client #2's wheelchair had been in need
due to the protruding spoke for almost

two wee

‘s. Further interview with the QIDP on

9/11/19 revealed she was made aware of the

Event ID:0Q2411

Facility ID: 922418

If continuation s!

sheet Page 9 of 10

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

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

34G089

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-SWANNANOA RESIDENTIAL

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

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

(X3) DATE SURVEY
COMPLETED

09/11/2019

condition of client #2's wheelchair by the PT staff
on 9/5/19 or 9/6/19. The QIDP also revealed that
she was not made aware PT personnel had to
contact the wheelchair company to complete the
repairs. The QIDP further verified the exposed
spoke to be a safety issue.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:0Q2411

(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 436 | Continued From page 9 W 436

Facility ID: 922418

If continuation sheet Page 10 of 10

inspection_type: MHLCS Annual