Average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Greens At Hendersonville during CMS and state inspections, most recent first.
Two residents had their MDS assessments inaccurately coded to reflect physician-prescribed weight loss regimens, despite no such orders being present. In both cases, staff responsible for completing the MDS did not verify the intent of weight changes or medication use with the RD or MDS Nurse, resulting in incorrect documentation of weight loss interventions.
The facility did not submit required Level II PASRR evaluations for three residents after new serious mental health diagnoses were identified, despite prior Level I determinations and clear indications for further screening. In each case, new psychiatric conditions such as delusional disorder and bipolar disorder were diagnosed, but no Level II PASRR requests were made due to lapses in communication and lack of a notification process between staff.
A resident with severe cognitive impairment was found with socks and rubber bands on their hands, causing swelling and blisters. The intervention was not documented or approved, and staff failed to question or remove the restraints over several days. The facility's policies on abuse and restraint were not followed, resulting in the resident's injuries.
A resident with Alzheimer's, dementia, and multiple sclerosis was found with socks and rubber bands on her hands, forming tourniquets, in a LTC facility. Despite visible injuries, multiple staff members failed to report the restraint, assuming it was a standard intervention. This oversight led to significant harm, revealing a breakdown in the facility's abuse and restraint policies.
A resident was found with socks and rubber bands tightly wrapped around her wrists, causing swelling and blisters. The initial report submitted by the DON inaccurately stated no apparent harm, as it was based on preliminary information. The report was submitted on time but lacked details about the injuries, which were to be included in a later investigation report.
The facility failed to maintain cleanliness and proper storage in its kitchen and nourishment areas. An opened soda bottle was improperly stored with resident food, and the milk cooler and ice machine were found unclean. The nourishment room refrigerator contained an undated opened nutritional supplement. The District Dietary Manager noted the absence of a cleaning checklist, and the Maintenance Director was unaware of the ice machine's condition.
A resident with dementia and diabetes continued to receive a higher dose of Trazadone despite a consultant pharmacist's recommendation for a Gradual Dose Reduction (GDR) and agreement from the NP. The order was not entered into the resident's chart due to oversight by the Unit Manager and confusion from a change in providers.
A resident with right-side paralysis and a healing fracture, who was 72 inches tall, experienced discomfort due to his feet pressing against the footboard when the bed was elevated. Despite reporting the issue to staff, no bed extender was provided. Observations and staff interviews confirmed the problem, but the maintenance department was not informed, although extenders were available. The DON and administrator acknowledged the oversight.
A resident with severe cognitive impairment was observed with a wheelchair armrest secured by tape, indicating a need for repair. Staff interviews revealed a communication breakdown, as the nurse aide did not notice the issue, and neither the Maintenance Director nor the Nurse Supervisor were informed. The DON and Administrator acknowledged that the repair should have been reported.
The facility failed to ensure air mattress settings matched the current weight of two residents, leading to a deficiency in pressure ulcer care. One resident's mattress was set at 182 pounds instead of 148.4 pounds, and another's was set at 252 pounds instead of 95.5 pounds. Nurses did not verify the settings despite initialing the MAR to confirm accuracy, as confirmed by the DON.
A facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling catheter and MRSA history. Two nurse aides did not wear gowns while assisting the resident, despite clear signage and available PPE. The aides acknowledged their oversight, and the DON confirmed the requirement for gowns during physical assistance.
A resident with hemiplegia and cognitive impairment fell during incontinence care when a nurse aide turned him away from her without side rails or additional assistance. The resident, who was holding onto a dresser, let go and fell, sustaining head and limb injuries. The aide had been trained to provide care alone, contrary to safer practices for residents with hemiplegia.
A resident with a history of COPD, heart failure, and anxiety disorder experienced an acute change in LOC, becoming lethargic and difficult to arouse. Despite multiple neuro checks indicating drowsiness and confusion, the resident remained at the facility until EMS was called, resulting in a significant delay in treatment. The resident was hospitalized for acute metabolic encephalopathy, respiratory failure, and other conditions. The nursing staff failed to notify the MD promptly, leading to the deficiency.
A resident with severe cognitive impairment experienced a decline in level of consciousness, but the nursing staff failed to notify the physician, resulting in delayed treatment for a possible opioid overdose. Despite observing the resident's deteriorating condition throughout the day, the staff only called EMS late in the afternoon.
The facility failed to report an allegation of neglect within the required 2-hour timeframe after a resident was hospitalized for a suspected opioid overdose. The resident, who was not prescribed opioids, tested positive for opiates and received naloxone. The facility became aware of the neglect allegation on 4/3/24 at 11:45 AM but delayed reporting it to the state agency.
The facility failed to verify the competency and skills of an agency nurse before she provided care to residents. The nurse worked her first shift without prior verification of her competency, due to an emergency staffing situation and the recent loss of the Scheduler responsible for setting up employee files. The facility did not confirm with the staffing agency that the nurse's skills had been checked.
Inaccurate MDS Coding for Weight Loss Regimens
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments regarding weight loss for two residents. For one resident with a diagnosis of malnutrition and a care plan addressing nutritional concerns, the quarterly MDS assessment was incorrectly coded to indicate the resident was on a physician-prescribed weight loss regimen. However, there were no physician orders for weight loss, and both the Registered Dietitian (RD) and MDS Nurse confirmed that the resident was not intended to lose weight nor prescribed any weight loss medication. The Dietary Technician, who completed Section K of the MDS, did not communicate this coding with the RD or MDS Nurse, leading to the inaccurate documentation. Another resident, with diagnoses including dementia, chronic kidney disease, and diabetes, experienced significant weight loss while receiving a diuretic medication as prescribed by a physician. The resident's MDS assessment was also coded as being on a physician-prescribed weight loss regimen, despite the absence of any such order. The RD and MDS Nurse clarified that diuretic use for fluid management should not be coded as a weight loss regimen unless specifically prescribed for that purpose. The Dietary Technician appeared to have misunderstood the intent of the medication and did not verify the coding with the RD or MDS Nurse. Interviews with facility staff, including the RD, MDS Nurse, and Administrator, revealed a lack of communication and verification regarding the coding of weight loss regimens on the MDS assessments. The Administrator stated that accurate coding is expected and that the Dietary Technician should have consulted with the RD and MDS Nurse when coding weight loss as physician-prescribed. The absence of such communication contributed to the inaccurate MDS documentation for both residents.
Failure to Submit Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for three residents after new serious mental disorder diagnoses were identified, despite previous Level I PASRR determinations. For one resident, the medical record showed a Level I PASRR determination with instructions that further screening was only required if a significant change occurred. The resident was later diagnosed with generalized anxiety disorder, delusional disorder, and hallucinations, but no Level II PASRR request was submitted. The social worker acknowledged awareness of the requirement but could not provide a reason for the omission. Another resident had a Level I PASRR determination and was admitted with unspecified psychosis and anxiety disorder. The resident later exhibited increased agitation and aggression, leading to the addition of a delusional disorder diagnosis and the initiation of antipsychotic medication. Despite these changes, there was no documentation of a Level II PASRR request following the new diagnosis. The social worker confirmed responsibility for submitting such requests and noted the absence of a process to notify her of new mental health diagnoses, resulting in delays. A third resident had a Level I PASRR completed prior to admission, with recommendations to resubmit for Level II if a new mental health diagnosis was suspected. The resident was later diagnosed with bipolar disorder, but no Level II PASRR request was documented. Interviews revealed that while the MDS nurse was supposed to notify the social worker of new diagnoses, there was no consistent system in place to ensure this communication, contributing to the failure to submit timely PASRR requests.
Resident Found with Unauthorized Restraints Leading to Injury
Penalty
Summary
The facility failed to protect a vulnerable resident's right to be free from physical restraints when a resident was found with socks placed on each hand, secured by rubber bands wrapped around each wrist. This incident involved a resident with severe cognitive impairment due to Alzheimer's disease, dementia, and multiple sclerosis, who required total staff assistance for all self-care tasks. The resident was observed with swollen hands, blisters, and red ligature marks on the wrists, indicating the use of restraints without medical justification or physician orders. The resident's care plan did not include any intervention involving the application of socks or rubber bands to the hands, and there were no physician orders for such restraints. Staff interviews revealed that the socks and rubber bands were likely applied to prevent the resident from engaging in coprophagy, a behavior noted in the care plan. However, this intervention was not documented or approved, and staff members were unsure who applied the restraints or how long they had been in place. Multiple staff members, including nurses and nurse aides, observed the resident with socks and rubber bands on the hands over several days but did not question or remove them, assuming it was a standard intervention. The facility's Director of Nursing and Administrator were informed of the incident, and an investigation was initiated. The use of socks and rubber bands as restraints was not an approved practice, and the facility's policies on abuse and restraint were not followed, leading to the resident's injuries.
Failure to Report and Address Inappropriate Restraint Use
Penalty
Summary
The facility failed to implement its abuse policy and procedure when nursing staff did not identify and immediately report the use of a physical restraint on a resident. The resident, who had Alzheimer's disease, dementia, and multiple sclerosis, was found with socks placed on her hands, secured by rubber bands wrapped around each wrist, effectively forming tourniquets. This restraint was not medically necessary, and there was no assessment for its need. The incident was observed by multiple staff members over several days, but none reported it to the Administrator or Director of Nursing Services as required by the facility's policy. The resident's condition deteriorated due to the restraint, with her right hand becoming edematous and bright red, and several blisters forming on the top and palm of the hand. The rubber bands had to be cut to remove the socks, and a wound nurse practitioner evaluated the resident, noting a large fluid-filled blister on the palm of her right hand. Despite the visible signs of injury and the facility's policy against restraints, staff members, including nurse aides and nurses, failed to question or report the use of the socks and rubber bands, assuming it was a standard intervention to prevent the resident from playing with her feces. Interviews with staff revealed a lack of communication and understanding of the facility's abuse and restraint policies. Several staff members admitted to seeing the socks and rubber bands on the resident's hands but did not report it, either because they assumed it was an approved intervention or because they were following the lead of more experienced staff. This failure to report and address the inappropriate use of restraints resulted in significant harm to the resident, highlighting a breakdown in the facility's procedures for preventing abuse and neglect.
Removal Plan
- Resident #1 was observed with a sock on both hands and rubber bindings had been placed around each wrist to hold the socks in place. This intervention caused swelling, redness, and a blister on resident #1's right hand and redness and swelling on the left hand. The facility failed to comply with the abuse policy when staff members were aware of the socks and/or rubber bindings and failed to report this form of restraint to facility administration. Because of the failure to report, the facility did not protect a resident with severe cognitive impairment from abuse through unnecessary restraints.
- Staff members who admitted to knowledge of the socks and/or rubber bindings being on resident #1's hands and failing to report, were suspended pending investigation by the Director of Nursing (DON). Staff interviews attest that staff members began seeing the socks and/or rubber binding.
- 1:1 education was provided verbally by DON to staff who reported knowledge of socks and/or rubber binding on resident #1's hands regarding abuse policy, restraint policy and the requirement to report suspected or actual abuse to the administrator or DON.
- Immediately following identification of concerns, DON initiated investigation. Investigation is ongoing by Administrator, DON, and Assistant Director of Nursing (ADON) and Unit Managers.
- All perpetrators who were aware of the use of socks and/or bindings on resident #1's hands, failed to report, and failed to remove the coverings and/or bindings are being terminated.
- In an ad hoc Quality Assurance Process Improvement (QAPI) meeting, the abuse and reporting policy was reviewed by the administrator to ensure no changes were needed. In attendance at this meeting were the DON, ADON, and Unit Managers. It was determined that no changes were needed.
- The DON completed interviews with all residents having a Brief Interview for Mental Status (BIMS) of 10 or greater to ensure that they had not experienced any abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- The DON completed skin assessment with all residents having a BIMS of 9 or less to ensure there was no visual indication of abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- DON and Administrator completed interviews with all staff working over the last 5 days. These staff members were interviewed to determine if they were aware of any other incidents of using interventions that restrict movement or abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- The Administrator reviewed all grievances and facility reported incidents for the last 30 days to ensure that there were no examples of a failure to report incidents as required by facility abuse and reporting policy. There were no new findings.
- The DON/Designee conducted all staff education in person and/or by telephone on the facility abuse and restraint-free policy to include a zero-tolerance for any type of resident abuse or failure to report an incident or suspected incident of abuse. Education also included that all residents have the right to be free from harm, including unnecessary or excessive physical restraint, including applying socks and bindings to hands to hinder manifestations of behaviors or for resident safety. Education focused not only on the requirement to report any unusual devices that could restrict movement, but to have open communication with the Administrator, DON, ADON, and Unit Managers about the resident population, asking questions or inquiring about any treatment or intervention that is new, uncommon, or suspected as possible abuse or a restraint. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities.
- DON or designee educated all staff in person and/or by telephone to proper notification and appropriate intervention for unsafe or other unusual behaviors. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities.
- During an ad hoc QAPI meeting, a root cause analysis was completed, and the root cause was identified as the need for additional staff education on the requirement to report unusual behavior or concerns about any intervention that restricts movement when visualized, as well as the requirement to report any incident or suspected incident of abuse immediately to the Administrator or DON. The decision was made to complete the following audits to maintain compliance with the plan of correction: DON/designee will interview 5 staff members weekly (on alternating shifts) for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- DON/designee will review the 24-hour report (that includes Sbars) 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- DON/designee will make a walking round 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- The facility administrator will review findings of audits to identify patterns or trends and will present audits to QAPI for 2 months, adjusting the plan as needed to maintain compliance.
Inaccurate Initial Report on Resident Injury
Penalty
Summary
The facility failed to submit an accurate initial report to the State Agency regarding an incident involving a resident who was found with socks on her hands and rubber bands tightly wrapped around her wrists. This resulted in significant swelling and blistering of the resident's hands. The initial report, completed by the Director of Nursing (DON), inaccurately stated that there was no apparent harm to the resident, as the DON had not yet observed the resident's injuries firsthand and relied solely on the information provided by Nurse #1. The report was submitted within the required two-hour timeframe, but it lacked critical details about the extent of the resident's injuries. Photographic evidence and staff interviews revealed that the resident's hands were swollen and had developed fluid-filled blisters due to the tight binding. The DON was informed of the incident shortly after it occurred and initiated an investigation, but the initial report did not reflect the severity of the injuries. The Regional Director of Operations acknowledged that the DON prioritized timely submission over accuracy, intending to include the full extent of the injuries in a subsequent 5-day investigation report.
Deficiencies in Kitchen and Nourishment Area Cleanliness and Storage
Penalty
Summary
The facility failed to properly store and maintain cleanliness in its kitchen and nourishment areas, as observed by surveyors. An opened soda bottle belonging to a staff member was found in a refrigerator meant for resident food storage, indicating improper storage practices. Additionally, the milk cooler contained baking sheets with a dried white and fuzzy greenish to brownish substance, suggesting inadequate cleaning. The ice machine's plastic shield was unclean, with an orange/pink substance touching the ice, and the floor drain cover had a thick layer of slimy white and pinkish/red substance. Furthermore, the storage rack for baking sheets had a thick buildup of a yellow, waxy substance. The nourishment room refrigerator contained an opened nutritional supplement without an open date, which was placed by a nurse after the refrigerator had been checked for opened and expired items. The District Dietary Manager, who had recently taken over, acknowledged the lack of a cleaning sheet for staff to sign off on completed tasks and mentioned that the previous manager did not implement such a system. The Maintenance Director stated that the ice machine was cleaned monthly and as needed, but was unaware of the current state of the kitchen ice machine. The Administrator confirmed that dirty areas should be cleaned regularly and that items in the nourishment room refrigerator should be dated and disposed of when expired.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to follow up on a consultant pharmacist's recommendation for a Gradual Dose Reduction (GDR) of Trazadone for a resident with dementia and diabetes mellitus. The resident was admitted with severe cognitive impairment and was receiving an antidepressant. The consultant pharmacist recommended a GDR from Trazadone 50 mg to 25 mg, which was agreed upon by the Nurse Practitioner (NP) and signed on two occasions, but the order was not entered into the resident's chart in September 2024. Consequently, the resident continued to receive the higher dose until late October 2024. Interviews with the Consultant Pharmacist, NP, Unit Manager, Director of Nursing (DON), and Administrator revealed a breakdown in communication and responsibility. The Consultant Pharmacist provided recommendations to the DON, who then passed them to the providers. The NP, new to the facility, was unaware that the order was not entered after signing it. The Unit Manager admitted to overlooking the recommendation and failing to enter the order. The DON acknowledged confusion due to a change in providers, which contributed to the oversight.
Failure to Provide Bed Extender for Tall Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident who was 72 inches tall and required a bed extender to prevent his feet from pressing against the footboard. The resident, who was cognitively intact but dependent on staff for bed mobility due to right-side paralysis and a healing left fibula fracture, reported discomfort from his feet being pushed against the footboard when the head of the bed was elevated. Despite expressing his discomfort to staff shortly after admission, no action was taken to provide a bed extender. Observations confirmed the resident's feet were pressed against the footboard, and interviews with the physical therapist, occupational therapist assistant, and nursing assistant revealed awareness of the issue but no communication to maintenance for a bed extender. The maintenance director stated he had not been notified of the need for a bed extender, although extenders were available. The director of nursing and the administrator acknowledged the oversight, indicating that the need for a bed extender should have been reported and addressed.
Failure to Maintain Wheelchair Armrest in Good Repair
Penalty
Summary
The facility failed to maintain the armrest of a resident's wheelchair in good repair, compromising the resident's right to a safe, clean, and homelike environment. The resident, who had severe cognitive impairment, was observed on multiple occasions with the left armrest of their wheelchair secured by four rows of purple tape. Despite the armrest material not being cracked, broken, or frayed, the use of tape indicated a need for repair that was not addressed. Interviews with staff revealed a breakdown in communication regarding the repair needs of the wheelchair. A nurse aide, who regularly assisted the resident, admitted to not noticing the condition of the armrest and therefore did not report it. The Maintenance Director and Nurse Supervisor both confirmed they had not been informed of the issue, and the Director of Nursing acknowledged that staff should have reported the need for repair. The Administrator also expressed an expectation that the staff should have notified the Maintenance Director to ensure timely repairs.
Failure to Ensure Correct Air Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that the air mattress settings matched the current weight of two residents, leading to a deficiency in pressure ulcer care. Resident #41, who was admitted with an unstageable pressure ulcer that had reopened, had an air mattress setting that was incorrectly set at 182 pounds, despite the resident's actual weight being 148.4 pounds. The nurse responsible for Resident #41 admitted to not checking the weight settings on the air mattress, even though she initialed the Medication Administration Record (MAR) indicating that the settings were correct. Similarly, Resident #37, who was at risk for developing pressure ulcers due to dementia and malnutrition, had an air mattress setting of 252 pounds, while the resident's actual weight was 95.5 pounds. The nurse assigned to Resident #37 also failed to verify the weight settings, despite initialing the MAR to confirm the settings were correct. Both instances were confirmed by the Director of Nursing, who acknowledged that the nurses should have visually checked the weight settings to ensure they matched the residents' current weights.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with an indwelling catheter. The policy required staff to wear gloves and gowns during high-contact activities such as transferring, toileting, and medical device care. However, during observations, two nurse aides did not follow these procedures. Nurse Aide #2 and Nurse Aide #3 were observed assisting a resident with transferring from bed to a wheelchair without donning gowns, despite the EBP signage posted on the resident's door and the availability of personal protective equipment outside the room. The resident involved had an indwelling urinary catheter and a history of methicillin-resistant staphylococcus aureus (MRSA), necessitating the use of EBP. During interviews, both nurse aides acknowledged their failure to wear gowns during high-contact activities, citing reasons such as not noticing the signage or being unaware of the resident's EBP status. The Director of Nursing confirmed the requirement for gowns during physical assistance, and the Administrator noted that staff had been educated on EBP requirements, indicating that the nurse aides should have followed the posted instructions.
Unsafe Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide incontinence care in a safe manner for a resident with a history of stroke, hemiplegia, repeated falls, and aphasia. The resident was moderately cognitively impaired and required assistance with bed mobility. During incontinence care, a nurse aide used a bed pad to turn the resident away from her while changing the bed sheet. The resident, using his unaffected arm to hold onto a dresser, let go and fell face-first onto the floor, hitting his head on the dresser. This resulted in a bruise on the left side of his head, a skin tear on the left knee and elbow, and injuries to his right hand. The nurse aide had been trained by other staff that the resident required only one-person assistance for incontinence care and linen changes, and to roll him away from her, despite the absence of side rails or additional staff assistance. The nurse's note confirmed the fall occurred during care with a CNA present. The resident was sent to the hospital for evaluation, where he was found to have a forehead hematoma and facial laceration, which did not require sutures. The physician who assessed the resident after the fall did not believe the delay in hospital transfer caused harm.
Failure to Initiate Timely Medical Services for Resident with Acute Change in LOC
Penalty
Summary
The facility failed to initiate timely medical services for a resident experiencing an acute change in the level of consciousness (LOC). The resident, who had a history of chronic obstructive pulmonary disease (COPD), heart failure, and anxiety disorder, was noted to be lethargic and difficult to arouse starting at 8:30 AM. Despite multiple neuro checks indicating drowsiness and confusion, the resident remained at the facility until emergency medical services (EMS) were called at 5:47 PM, resulting in a significant delay in treatment. The resident was subsequently admitted to the hospital for acute metabolic encephalopathy, acute on chronic hypoxemic respiratory failure with hypoxia, possible aspiration pneumonia, and pulmonary hypertension, and remained hospitalized for ten days. The report details that the resident's care plan included monitoring for side effects of pain medication and reporting any complaints of pain or requests for treatment. However, the resident was not on any opioid medications according to the Medication Administration Record (MAR). On the day of the incident, the resident received multiple medications, including Levothyroxine, Lidocaine patch, Diltiazem, Pregabalin, Torsemide, Albuterol sulfate, Diclofenac Sodium gel, Acetaminophen, Saline nasal gel, Fluticasone-Umeclidin-valiant, and Clonazepam. Despite the resident's deteriorating condition, the nursing staff did not notify the medical doctor (MD) until much later in the day. Interviews with the nursing staff revealed that the resident's lethargy and decreased LOC were observed throughout the day, but the severity of the condition was not adequately communicated to the Unit Manager or the MD. The Director of Nursing (DON) acknowledged that the nurses should have notified the MD immediately upon noticing the resident's decreased LOC. The hospital's urine drug screen was positive for opiates, leading to the administration of naloxone, which temporarily improved the resident's condition. The facility had naloxone available but did not suspect an opioid overdose due to the absence of opioid prescriptions in the resident's MAR. The delay in recognizing the severity of the resident's condition and initiating appropriate medical intervention led to the deficiency noted in the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's level of consciousness, resulting in a delay in the treatment of a possible opioid overdose. Resident #1, who had diagnoses including COPD, heart failure, and anxiety disorder, was noted to have a severely impaired cognition. On 3/31/24, neuro checks revealed a decline in the resident's level of consciousness from being alert at 7:00 AM to drowsy and confused by 8:30 AM. Despite further deterioration observed in neuro checks from 9:30 AM to 4:30 PM, there was no documentation that the physician was notified of these changes. The resident was eventually transferred to the hospital after emergency medical services were called at 5:47 PM. Interviews with the nursing staff revealed that Nurse #1 and Nurse #2 were aware of the resident's sleepiness and altered mental status but did not notify the physician. Instead, they monitored the resident's vital signs, which were normal, and placed the resident at the nurse's station for observation. Unit Manager #2 was informed of the resident's condition only after 5:00 PM, leading to the eventual call to EMS. The Director of Nursing acknowledged that the nurses should have notified the physician earlier when the resident's level of consciousness first decreased.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to submit an initial report to the state agency within the required 2-hour timeframe after receiving an allegation of neglect that resulted in hospitalization for a suspected opioid overdose for a resident who was not prescribed opioids. The resident was admitted to the hospital for drowsiness, altered mentation, and appeared disoriented and weak. A urine drug screen revealed the resident was positive for opiates, and the hospital administered two doses of naloxone. The facility became aware of the neglect allegation on 4/3/24 at 11:45 AM but did not report it to the state agency until after this time. The Police Detective contacted the facility on 4/2/24 and served a subpoena for the resident's medical records, indicating a potential or possible negligence related to medication. The Administrator was notified of the subpoena after 4:30 PM on 4/2/24 and was informed that a second Police Detective would return the next morning to explain the details. On 4/3/24 at approximately 11:45 AM, the Police Detective reported the family's allegation of neglect related to medication, prompting the Administrator to call the Department of Social Services and send the initial report to the state agency. The Administrator considered the incident a possible medication error rather than a report of abuse or neglect.
Failure to Verify Competency of Agency Nurse
Penalty
Summary
The facility failed to verify or check the competency and skills of an agency nurse (Nurse #3) before she provided care and services to residents. The employee file for Nurse #3 only contained verification of an active and unencumbered license to practice in the state, but there was no documentation confirming that her skills or competencies were checked. Nurse #3 worked her first shift at the facility on 3/30/24 without prior verification of her competency by the facility. This lapse occurred despite the facility's contract with the staffing agency, which stipulated that the agency should ensure the competency of their staff before sending them to the facility. The Director of Nursing (DON) and Administrator acknowledged that the competency check was not performed due to an emergency staffing situation on a holiday and the recent loss of the Scheduler responsible for setting up employee files, including competency checks for agency staff. The Administrator confirmed that the newly hired Scheduler, who was still in training, would be tasked with setting up these records in the future. However, at the time of the incident, the facility did not verify with the staffing agency that Nurse #3's skills and competencies had been checked before her shift on 3/30/24.
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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) |
|---|---|---|---|---|
| Valley Hill Health & Rehab Center | 1.5 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Hendersonville | 2.4 mi | ★★★★★ | 4 | 0 |
| Carolina Village Inc | 2.6 mi | ★★★★★ | 0 | 0 |
| Orchard Valley Health And Rehabilitation | 2.8 mi | ★★★★★ | 14 | 0 |
| Life Care Center Of Hendersonville | 2.9 mi | ★★★★★ | 5 | 0 |
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