Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Hendersonville during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least 8 consecutive hours on multiple days, as confirmed by staffing records and staff interviews. Scheduling gaps occurred, particularly on weekends, and documentation was lacking for required RN presence on several dates.
Surveyors identified expired milk in the walk-in cooler, unlabeled and undated chicken in the freezer, open and undated food items and supplements stored on the floor in dry storage, a dirty ice machine, and an unclean nourishment refrigerator. Staff interviews confirmed these practices did not meet facility expectations for food safety and sanitation.
Two residents did not receive their physician-ordered therapeutic diets and nutritional supplements. One resident with diabetes and malnutrition was not given double portions as ordered, and another resident at risk for weight fluctuation did not receive a prescribed frozen nutritional supplement due to it being out of stock. Staff failed to ensure orders were followed and did not notify nursing when supplements were unavailable.
A treatment nurse failed to follow infection control protocols by not wearing a gown during wound care for a resident with a diabetic foot ulcer and during tracheostomy and feeding tube care for another resident on Enhanced Barrier Precautions (EBP). The nurse also did not remove gloves and perform hand hygiene between dirty and clean tasks during a feeding tube dressing change, contrary to facility policy. The DON and Administrator confirmed that EBP and hand hygiene protocols were expected to be followed during these care activities.
The facility did not ensure that daily nurse staffing sheets accurately matched the actual nursing staff who worked, as shown by discrepancies between posted sheets and time clock records. Staff interviews revealed inconsistent processes for updating and posting staffing information, leading to inaccurate documentation of RN and LPN coverage on multiple days.
A resident developed a stage 2 pressure ulcer, but the nurse failed to notify the Physician or PA and did not document the occurrence or treatment. The facility's protocol required such notification and obtaining treatment orders, which was not followed, leading to a deficiency.
A resident at risk for pressure ulcers did not receive timely care due to the facility's failure to complete weekly skin assessments and obtain treatment orders for a newly identified sacral ulcer. The ulcer was discovered by a nurse who did not document the occurrence or notify the PA for treatment orders, resulting in a five-day delay in care. The DON and Administrator expected nurses to follow protocol by contacting the Physician or PA for treatment orders, which was not adhered to in this instance.
The facility failed to properly manage medication storage, with an opened bottle of Latanoprost eye drops stored beyond the manufacturer's recommended period and an expired Povidone Iodine solution found in medication carts. Nurses acknowledged the oversights, and the DON expressed confusion over the missed expired medications despite previous training and audits.
A facility failed to complete a comprehensive MDS assessment within 14 days of the ARD for a resident. The delay was due to the absence of a permanent MDS Coordinator, with staff from other facilities focusing on current assessments to prevent further delays. The Administrator identified the issue during an audit and attributed it to having only one permanent MDS Coordinator, with plans to address the backlog by hiring an additional coordinator.
The facility failed to complete quarterly MDS assessments within the required timeframe for three residents. The delay was due to the absence of a permanent MDS Coordinator, with staff from other facilities focusing on current assessments to prevent further delays. The issue was identified during an audit, and the facility has since hired an additional MDS Coordinator.
A facility failed to complete a discharge-return anticipated MDS and an entry tracking record within the required timeframe for a resident. The delay was due to the absence of a dedicated MDS Coordinator, leading to a backlog of assessments. The issue was identified during an audit, and the facility had been relying on staff from other facilities to assist, which was insufficient to address the backlog.
A resident with multiple diagnoses requiring total assistance for transfers fell and sustained a hip fracture after a nurse aide attempted an independent transfer without a mechanical lift. The care plan lacked clear documentation of the resident's transfer needs. In another case, a resident with multiple sclerosis was transferred without the required mechanical lift and two-person assistance, contrary to the care plan.
The facility failed to maintain cleanliness and proper labeling in the kitchen and nourishment areas. Observations revealed debris on a kitchen fan and in the walk-in cooler, along with undated and expired food items. The Dietary Manager and Administrator expected cleanliness and proper labeling, but the Dietary Manager was unaware of cleaning responsibilities. Unlabeled and undated items were also found in nourishment rooms, with dietary aides responsible for labeling and discarding items.
A facility failed to accurately code MDS assessments for several residents, leading to documentation deficiencies. A resident's fall and resulting fracture were not recorded, another's anticoagulant use and hand contracture were omitted, and significant weight loss in a third resident was not documented. Additional errors included unrecorded bowel incontinence and a colostomy. The Corporate MDS Consultant attributed these inaccuracies to the health issues of the MDS Coordinator.
The facility failed to date open bottles of latanoprost eye drops and multi-dose vials of tuberculin, and did not remove expired medications and vaccines from medication room refrigerators. Staff interviews revealed a lack of awareness and responsibility for these tasks.
The facility did not provide all food items as specified by the planned menu for residents on a pureed diet. During a lunch meal observation, pureed chicken and dumplings and pureed beets were served, but pureed bread was missing. The Dietary Manager and RD were unsure why the bread was not prepared, and the Administrator expected the menu to be followed unless an RD-approved substitution was made.
A facility failed to ensure a resident's physician's order for an advanced directive matched the MOST form signed by the family. The resident was admitted with a full code status, but the family changed it to DNR with limited interventions. The electronic health record still showed a full code status due to an oversight in the review process. The ADON, DON, and Executive Director acknowledged the discrepancy and the expectation for records to match.
A resident with anemia and malnutrition was not provided yogurt with meals despite multiple requests, as confirmed by observations and interviews. The Dietary Manager was aware of the request but had not audited meal trays to ensure compliance. The facility's Administrator expected food preferences to be followed.
The facility failed to provide nighttime snacks for three residents, who reported a lack of variety and availability in the nourishment rooms. Observations confirmed limited snack options, and interviews revealed unclear responsibilities for stocking snacks. The practice of preparing labeled snack trays was discontinued.
A resident with severe cognitive impairment and dependency on staff for daily living activities did not receive necessary oral hygiene assistance. Observations showed dirty dentures and teeth with a white buildup, indicating a lack of care. Staff interviews revealed a lack of awareness and communication about the resident's needs, despite expectations for daily assistance.
A resident with dysphagia and diabetes, dependent on staff for care, did not receive the correct tube feeding as per physician's order. The RD recommended specific settings to meet nutritional needs, but observations showed the feeding was set incorrectly. The DON confirmed the error, and the Physician Assistant emphasized the importance of following RD's recommendations. Attempts to interview the responsible nurse were unsuccessful.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day on five specific dates within the reviewed period. Review of daily nurse staffing sheets and time clock reports revealed that on these dates, there was no documentation of an RN being present for the required duration. Staff interviews confirmed that there were times when no RN was scheduled for the full 8 to 12 hours, and the Central Supply Manager, who was responsible for scheduling, would notify the Former Administrator when this occurred. The Former Administrator acknowledged awareness of the issue, particularly on weekends, and described attempts to address it by alternating the MDS Nurse and Treatment Nurse, both RNs, on weekends, but could not recall when this system was implemented. The Regional Director of Clinical Operations also confirmed the lack of documentation for RN coverage on the identified dates and noted that there may have been instances of call-outs or staff working at a sister facility, which contributed to the deficiency. The report does not mention any specific residents affected or provide details about their medical conditions at the time of the deficiency. The deficiency was identified through record review and staff interviews, which consistently indicated that the facility did not meet the regulatory requirement for RN coverage on the specified dates.
Deficiencies in Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and sanitation practices within the facility. In the walk-in cooler, a box of 2% milk cartons was found with a use-by date that had already passed, and both the Dietary Manager and Administrator confirmed that expired items should be discarded by the use-by date. In the walk-in freezer, a bag of boneless chicken breasts was found without a label or date, contrary to facility expectations. The dry storage room contained open and undated bags of powdered sugar and graham crackers, as well as boxes of nutritional supplements stored directly on the floor, all of which were acknowledged by staff and administration as not meeting facility standards for labeling, dating, and storage. Further observations revealed sanitation issues with equipment and nourishment storage. The dining room ice machine had a visible build-up of gray debris on the left vent, and while a contract company handled quarterly deep cleaning, the Maintenance Director was responsible for routine cleaning and had not been notified of the issue. Additionally, the nourishment room refrigerator on the 500/600 hall had a large area of dried white substance with cardboard stuck to the middle shelf, which staff and administration stated should be checked and cleaned daily. These findings were confirmed through staff interviews, indicating lapses in routine monitoring and adherence to established food safety and sanitation protocols.
Failure to Provide Physician-Ordered Therapeutic Diets and Supplements
Penalty
Summary
The facility failed to follow physician diet orders for two residents with specific nutritional needs. One resident, admitted with diabetes and malnutrition, had a physician order for a mechanical soft diet with double portions as an intervention for weight loss. Despite this, observations during a lunch meal revealed the resident did not receive a double portion of beef as ordered. Staff interviews confirmed that the dietary aide responsible for checking meal trays overlooked providing the double portion, and the dietary manager and registered dietitian both stated that double portions were expected to be provided as ordered. Another resident, admitted with a history of stroke and at risk for weight fluctuation, had a physician order for a frozen nutritional supplement twice daily. Observations on two consecutive days showed that the resident did not receive the ordered supplement with her lunch meal because the kitchen was out of the product. Staff interviews revealed that dietary staff did not notify nursing staff or the dietary manager about the unavailability of the supplement, and the registered dietitian confirmed that staff should have notified nursing so an appropriate substitute could be ordered. The administrator also stated that she expected residents to receive supplements as ordered and for nursing to be notified if they were unavailable.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) and hand hygiene during care for residents with chronic wounds and indwelling medical devices. Specifically, a treatment nurse did not wear a protective gown while providing wound care for a resident with a diabetic foot ulcer, despite the facility's EBP policy indicating that diabetic foot ulcers are considered chronic wounds and require EBP during high-contact care activities. The nurse and the Director of Nursing (DON) both stated that EBP was not implemented because the wound was not present for three months, although the policy listed diabetic foot ulcers as chronic wounds regardless of duration. The Administrator later confirmed that EBP should have been implemented for this resident during wound care. Additionally, the same treatment nurse did not don a gown while providing tracheostomy and feeding tube care for another resident who was on EBP, as indicated by signage and supplies at the resident's door. The nurse performed multiple steps of tracheostomy and feeding tube care, including handling soiled dressings and cleaning around the devices, without wearing a gown as required by the facility's EBP policy. The nurse acknowledged this omission as an oversight during an interview, and both the DON and Administrator confirmed that staff are expected to follow EBP protocols during such care. The facility also failed to follow its hand hygiene policy during a dressing change for a resident with a feeding tube. The treatment nurse did not remove gloves and perform hand hygiene after removing a soiled gauze and before cleaning around the feeding tube, contrary to the facility's policy and CDC guidelines. The nurse stated she would only remove gloves and perform hand hygiene if the gloves were visibly soiled, while the DON and Administrator both indicated that hand hygiene should be performed when moving from a dirty to a clean task.
Inaccurate Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets accurately reflected the nursing staff who worked on four out of six days reviewed. Record review showed discrepancies between the posted staffing sheets and the actual time clock reports. On several occasions, the staffing sheets indicated that a Registered Nurse (RN) was present during the day shift, while the time clock reports revealed that only Licensed Practical Nurses (LPNs) were present and no RN had worked. On another occasion, the staffing sheet did not list an RN, but the time clock report showed that an RN had worked for three hours during the shift. Interviews with facility staff revealed inconsistencies in the process for completing and updating the daily nurse staffing sheets. The Assistant Director of Nursing (ADON) was responsible for updating the sheets during the week, while the weekend nursing supervisor was responsible on weekends. However, the Central Supply Manager reported that she sometimes completed the sheets in advance for the weekend, and the receptionist would post them, with nursing staff expected to update them as needed for call-outs or schedule changes. The Administrator confirmed these responsibilities and stated that the expectation was for the sheets to be updated to accurately reflect the staff who worked each shift.
Failure to Notify Physician of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the Physician or Physician Assistant (PA) about a newly identified pressure ulcer for one of the residents. Resident #3, who was admitted with diagnoses including dementia and protein-calorie malnutrition, developed a stage 2 pressure ulcer on the sacrum, first identified on 10/18/24. Nurse #1, who completed the wound observation tool on 10/24/24, was aware of the new wound but did not document the occurrence or treatment, nor did she inform the PA about the wound. This lack of communication and documentation led to a failure in obtaining necessary treatment orders. Interviews with the PA, Director of Nursing (DON), and the Administrator revealed that the facility's protocol required nurses to notify the Physician or PA and obtain treatment orders when a new wound is discovered. The PA expressed a preference for being notified as soon as possible about skin issues that could result in pressure ulcers. The DON and Administrator both confirmed that Nurse #1 did not follow the established protocol, which was an expectation for addressing new wounds in the facility.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident, who was admitted with diagnoses including dementia and protein-calorie malnutrition, was at risk for pressure ulcers due to decreased mobility. Despite being identified as at risk, the facility did not complete weekly skin assessments or obtain treatment orders for a newly identified pressure ulcer on the resident's sacrum. The pressure ulcer was first identified on October 18, 2024, but there was no documentation of its discovery or initial treatment until October 24, 2024, when a physician's order was finally obtained. Nurse #1, who discovered the wound, did not document the occurrence or treatment of the wound and failed to notify the Physician Assistant (PA) to obtain treatment orders. The PA indicated that while treatment orders would have been beneficial, the delay did not impact the outcome due to the resident's poor nutrition and refusal to offload. The Director of Nursing (DON) and the Administrator both expressed that their expectation was for nurses to contact the Physician or PA and obtain treatment orders when a new wound is discovered, which was not done in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage guidelines, resulting in deficiencies related to expired and improperly stored medications. During a medication storage audit, an opened bottle of Latanoprost eye drops was found in a medication cart, having been stored at room temperature since 04/28/24, contrary to the manufacturer's guidelines which allow room temperature storage for only up to six weeks. Nurse #1, who was present during the audit, acknowledged the oversight, mistakenly believing the medication could be stored until its expiration date in June 2026. Additionally, another audit revealed an expired antiseptic wound care solution, Povidone Iodine 10%, in a different medication cart. The solution had expired on 10/31/23 but was still present and ready for use. Nurse #2, who was present during this audit, admitted to missing the expired solution during her morning check. The Director of Nursing expressed confusion over the oversight, despite previous in-service training and audits, and emphasized the expectation for the facility to remain free of expired medications.
Failure to Complete MDS Assessment Timely
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for one of the sampled residents. The resident was admitted to the facility, and their annual MDS assessment was noted as in progress with an ARD of 08/01/24. The Corporate MDS Consultant confirmed that the assessment was not completed within the regulatory timeframe due to the facility being without a permanent MDS Coordinator for some time. Staff from other facilities had been assisting but focused on current assessments to prevent further delays. The Administrator became aware of the issue during an audit for the Plan of Correction from a previous recertification survey. The delay was attributed to having only one permanent MDS Coordinator, and the facility had recently hired an additional coordinator to address the backlog. The Administrator expected MDS assessments to be completed within the regulatory timeframes.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14 days of the Assessment Reference Date (ARD) for three residents. Resident #2's quarterly MDS assessment, with an ARD of 07/23/24, was still in progress as of 08/22/24. Similarly, Resident #5's assessment with an ARD of 07/26/24 and Resident #3's assessment with an ARD of 08/06/24 were also noted as in progress. The Corporate MDS Consultant confirmed that these assessments were not completed within the regulatory timeframe. The delay in completing the MDS assessments was attributed to the facility being without a permanent MDS Coordinator for some time. Staff from other facilities had been assisting, focusing on current MDS assessments to prevent further delays. The Administrator acknowledged the issue during an audit for the Plan of Correction from a previous recertification survey and attributed the breakdown to having only one permanent MDS Coordinator. The facility has since hired an additional MDS Coordinator to address the backlog.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) within 14 days of the discharge date and an entry tracking record within 14 days of admission for one of the sampled residents. Resident #5 was admitted to the facility, and upon review of their electronic health record, it was found that both the discharge-return anticipated MDS assessment and the entry tracking record were still in progress beyond the regulatory timeframe. This deficiency was confirmed during a telephone interview with the Corporate MDS Consultant, who acknowledged the delay and attributed it to the absence of a dedicated MDS Coordinator. The Administrator became aware of the issue during an audit for the Plan of Correction from a previous recertification survey. The delay in completing MDS assessments was primarily due to having only one permanent MDS Coordinator, which led to a backlog. The Administrator discussed the issue with the Corporate MDS Consultant, who was focusing on current assessments to prevent further delays. The facility had been relying on staff from other facilities to assist, but this was insufficient to address the backlog in a timely manner.
Failure to Follow Transfer Protocols Leads to Resident Injuries
Penalty
Summary
The facility failed to include a resident's transfer status in the comprehensive care plan, leading to an unsafe transfer attempt by a nurse aide. Resident #44, who had multiple diagnoses including muscle weakness and hip contractures, required total dependence for transfers due to lower extremity weakness. On the evening of 05/17/24, Nurse Aide #1 attempted to transfer Resident #44 from a motorized wheelchair to the bed without assistance or a mechanical lift, resulting in the resident falling to the floor. The resident sustained an acute left intertrochanteric fracture and was admitted to the hospital for surgical repair. The incident was compounded by the lack of clear documentation and communication regarding Resident #44's transfer needs. The nurse aide was not aware of the resident's transfer status and did not seek assistance or clarification before attempting the transfer. The care plan was only updated after the incident to reflect the need for total staff assistance with transfers. Interviews with staff and the resident revealed inconsistencies in the nurse aide's account of the incident, and the facility's investigation determined that the fall was due to the nurse aide's failure to follow proper transfer protocols. In a separate incident, Resident #8, who was dependent on staff for transfers due to multiple sclerosis, was transferred by NA #2 without the use of a mechanical lift and two-person assistance as required by the care plan. The aide used one-person physical assistance, believing it was safe due to the resident's ability to bear weight on one leg. This action was contrary to the care plan, which specified the use of a total mechanical lift with two-person assistance. The aide had not recently checked the care plan and did not inform therapy or nursing staff of the resident's ability to bear weight and pivot with one-person assistance.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen and nourishment areas, as observed during a survey. A fan in the food preparation area was found with gray debris on its covers, and the walk-in cooler had a thick build-up of gray debris near the ceiling light and entry door wall. The Dietary Manager, who had been employed for about a month, was unaware of any deep cleaning schedule or who was responsible for cleaning these areas. The Administrator expected all kitchen fans and the walk-in cooler to be clean and free of debris. In the walk-in cooler, several food items were found opened and undated, including sliced cheese, cottage cheese, shredded cheese, loaves of bread, and a bag of shredded carrots. Additionally, iceberg lettuce showed signs of spoilage, and collard greens were past their best-by date. Manufactured milkshakes were not labeled with the date they were removed from the freezer. The Dietary Manager expected all food items to be labeled and dated, and spoiled or expired food to be discarded. The Administrator shared these expectations, including the use or disposal of milkshakes within 14 days of thawing. Further observations revealed an opened and undated bag of French fries in the walk-in freezer and expired food items on a food preparation table. In nourishment rooms, various food and beverage items were found unlabeled and undated, including milkshakes, water, pineapple juice, diet soda, salad, and cake. The Dietary Manager stated that dietary aides were responsible for labeling, dating, and discarding items each shift. The Administrator expected all food and beverage items to be labeled and dated, with milkshakes used or discarded within 14 days of thawing.
Inaccurate MDS Coding Leads to Documentation Deficiencies
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #44, who was admitted with diagnoses including abnormal gait and muscle weakness, experienced a fall resulting in a hip fracture. However, the MDS assessment did not reflect this fall or the fracture, indicating a significant oversight in the documentation process. The Corporate MDS Consultant acknowledged that the MDS should have accurately recorded the fall and fracture. Resident #17, admitted with hemiplegia and hemiparesis following a stroke, was prescribed Xarelto, an anticoagulant medication. Despite this, the MDS assessment failed to document the use of anticoagulant medication and the impairment of the resident's upper extremities due to a right-hand contracture. Similarly, Resident #13, who experienced a significant weight loss over six months, was not accurately coded in the MDS assessment to reflect this weight loss. The Corporate MDS Consultant confirmed these inaccuracies, attributing them to the health problems of the facility's MDS Coordinator. Additional coding errors were identified for Resident #7, whose bowel incontinence was not documented, and Resident #2, whose colostomy was not recorded in the MDS assessment. These omissions were also confirmed by the Corporate MDS Consultant, who cited the MDS Coordinator's health issues as a contributing factor. The facility's Administrator expressed an expectation for accurate MDS assessments, highlighting a gap between expected and actual documentation practices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications and biologicals according to professional standards. Specifically, two open bottles of latanoprost eye drops were found on a medication cart without being dated, which is necessary to track their usage duration. Nurse #1, who was interviewed, was unaware of how long the eye drops had been in use and admitted to not being the usual nurse assigned to that medication cart. The Director of Nursing (DON) and the Administrator confirmed that the expectation was for the nurse who removed the eye drops from refrigeration to date them when placed on the cart. Additionally, the facility did not date three multi-dose vials of tuberculin purified protein derivative, which were stored in the medication room refrigerators. These vials should be discarded if in use for more than 30 days. Furthermore, expired medications and influenza vaccines were found in the medication room refrigerators. The DON and the Infection Preventionist were responsible for checking these items, but the Infection Preventionist was unaware of her responsibility to check the expiration dates of the influenza vaccines. The Administrator expected regular checks of the medication rooms to ensure expired items were removed.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to provide all food items as specified by the planned menu for residents receiving a pureed diet. During an observation of the lunch meal tray line, it was noted that pureed chicken and dumplings and pureed beets were served using a 4-ounce serving utensil, but no pureed bread was provided on the pureed meal trays. The menu for the lunch meal specified that a 4-ounce serving of pureed chicken and dumplings, a 4-ounce serving of pureed beets, and one serving of pureed bread mix were to be served. The Dietary Manager was unable to explain why the pureed bread was not prepared, and the Registered Dietician expected the menu to be followed as planned. The Administrator also expected the menus to be followed unless a substitution approved by the RD was provided.
Mismatch Between Physician's Order and MOST Form for Resident's Code Status
Penalty
Summary
The facility failed to ensure that the physician's order for an advanced directive matched the Medical Orders for Scope of Treatment (MOST) form signed by the resident's family for one resident. The resident, who was moderately cognitively impaired, was admitted to the facility with a full code status as per the hospital's SBAR report. However, upon admission, the resident's family decided to change the code status to Do Not Resuscitate (DNR) with limited interventions, as documented in the MOST form. Despite this change, the electronic health record still reflected a full code status, leading to a discrepancy between the physician's order and the MOST form. The Assistant Director of Nursing (ADON) acknowledged that the facility's interdisciplinary team was responsible for reviewing new residents' code statuses to ensure accuracy, but this review was overlooked for the resident in question. The Director of Nursing (DON) and the Executive Director both stated that their expectation was for the code status in the electronic health record to match the MOST form. The oversight occurred because the resident was admitted on a Friday, and the review was supposed to take place the following Monday, but it was missed. Staff were trained to check the physical chart for the MOST form for the most up-to-date code status before providing medical intervention.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident #9, who was admitted with diagnoses including anemia and malnutrition. Despite being cognitively intact and having a regular diet order, Resident #9 expressed a preference for yogurt with each meal, which was not provided. This issue was identified through record reviews, observations, and interviews with the resident and staff. The resident's nutrition care plan, last revised in June 2024, did not reflect this preference, and observations over several days confirmed the absence of yogurt on her meal trays. The Dietary Manager acknowledged awareness of the resident's request for yogurt and confirmed its availability in the kitchen. However, he admitted to not conducting audits of meal trays to ensure compliance with residents' food preferences since his employment began a month prior. The facility's Administrator stated an expectation that residents' food preferences should be followed, indicating a lapse in the facility's adherence to dietary preferences for Resident #9.
Failure to Provide Nighttime Snacks
Penalty
Summary
The facility failed to offer and provide nighttime snacks for three of four sampled residents, as observed during a resident council meeting. Residents reported not being offered nighttime snacks and noted a lack of variety in the available snacks in the nourishment rooms. They expressed a desire for healthy snacks in the evenings, as they often felt hungry between their early dinner and the next morning's breakfast. Observations confirmed that the nourishment rooms had limited snack options, with only peanut butter crackers and saltine crackers available. Interviews with the Dietary Manager and the Administrator revealed a lack of clarity and responsibility regarding the stocking of nourishment rooms. The Dietary Manager indicated that snacks were available upon request before dietary staff left for the day, but was unsure who ensured the nourishment rooms were stocked. The Administrator, unaware of the limited snack availability, stated that all staff had access to the nourishment rooms to provide snacks upon request. However, the practice of preparing a tray of snacks labeled with residents' names, as done previously, was no longer in place.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary oral hygiene assistance to a resident with severe cognitive impairment and dependency on staff for daily living activities. Resident #64, who was admitted with diagnoses including dementia and seizure disorder, required setup assistance for oral hygiene as per their care plan. However, observations on multiple occasions revealed that the resident's dentures and teeth were visibly dirty with a white buildup of debris, indicating a lack of proper oral care. Interviews with staff, including the Director of Nursing (DON) and a nursing assistant (NA #3), highlighted a lack of awareness and communication regarding the resident's need for oral hygiene assistance. NA #3 was unaware that the resident had dentures and confirmed that no assistance was provided on specific dates. The DON acknowledged the need for cleaning but was unsure when the resident last received oral hygiene care. This deficiency in care was noted despite the facility's expectation for staff to provide daily oral hygiene assistance.
Failure to Follow Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of a high protein, fiber-fortified nutritional supplement for a resident who was receiving tube feeding. The resident, who had multiple diagnoses including dysphagia following a stroke and diabetes, was dependent on staff for all self-care tasks and received more than half of her total calories and fluid intake via tube feeding. The Registered Dietitian (RD) had recommended specific tube feeding settings to meet the resident's nutritional and hydration needs, which were not followed as per the physician's order. Observations revealed that the tube feeding was set at 50 ml/hr instead of the prescribed 55 ml/hr, with water flushes at 20 ml/hr. The Director of Nursing (DON) confirmed the discrepancy in the tube feeding settings and suggested that the nurse might have misread the order. The RD stated that her recommendations were based on the provider's agreement and the resident's tolerance, but she did not observe the incorrect settings herself. Attempts to interview the responsible nurse were unsuccessful, and the Physician Assistant expressed a preference for staff to follow the RD's recommendations. The facility administrator, not being clinical, could not comment on the expectations without consulting the nurse involved.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Hendersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carolina Village Inc | 0.3 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Hendersonville | 0.6 mi | ★★★★★ | 4 | 0 |
| The Greens At Hendersonville | 2.9 mi | ★★★★★ | 2 | 0 |
| Valley Hill Health & Rehab Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Orchard Valley Health And Rehabilitation | 3 mi | ★★★★★ | 14 | 0 |
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