Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Laurels Of Hendersonville during CMS and state inspections, most recent first.
Expired and discontinued medications were left available in multiple medication carts, including Pantoprazole, ABH Gel syringes, and Propranolol. The DON, an LPN, and a medication aide stated the medications should have been removed from the carts and placed in the return-to-pharmacy bin, but they remained on the 100-hall cart and both 200-hall carts.
A resident admitted with PTSD did not have a Level II PASRR evaluation requested even though the diagnosis was present on admission and listed as an active psychiatric/mood disorder on the MDS. The SW Assistant said she relied on a recent Level I PASRR from the hospital and did not request a Level II review, while the Administrator stated that a Level II PASRR request should be made for a resident with a serious mental health diagnosis.
Failure to Request Level II PASRR Reevaluation After Significant Change: A resident with schizoaffective disorder, dementia with psychotic disturbance, and unspecified psychosis had a Level II PASRR with no expiration date, and a significant change MDS identified serious mental illness and/or ID-related conditions. The SW Assistant did not submit a Level II PASRR reevaluation request, stating she believed it was only needed if the change directly related to the mental illness and that the resident's mental status had not changed; the Administrator stated reevaluation requests should be made when a resident has a significant change in condition.
A facility failed to promptly remove and return discontinued oxycodone-acetaminophen after a resident was discharged, resulting in a missing blister card of the controlled substance. Inconsistent documentation and failure to follow policy for notifying the DON and removing narcotics from the medication cart led to the misappropriation of medication. The incident involved discrepancies in count sheets, late entries by nursing staff, and required investigation by facility leadership and law enforcement.
The facility failed to maintain proper garbage disposal practices, with open dumpster lids and poorly maintained garbage cans. Staff interviews revealed a lack of awareness and responsibility for maintaining the dumpster area, which is crucial for pest control.
The facility failed to complete daily nurse staffing sheets for 50 out of 76 days due to the absence of a backup plan when the responsible Medical Records Clerk was not working. Interviews revealed that the Administrator was unaware of the issue, and no one else was assigned to complete the sheets in the clerk's absence, leading to the deficiency.
A resident with dementia and a history of falls was left unsupervised in an unlocked wheelchair during a shower, leading to a fall and a right femoral neck fracture. The resident's care plan, which included measures for fall prevention, was not followed, resulting in significant medical complications and the resident's eventual death. Staff interviews indicated a lack of adherence to necessary precautions for high-risk residents.
Expired and Discontinued Medications Left in Medication Carts
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices because expired and discontinued medications were left in medication carts. During an observation with the DON, the 200-hall upper medication cart contained a Pantoprazole 40 mg medication card with 27 pills remaining and a pharmacy expiration date of 5/31/26, even though the physician’s order had been discontinued on 3/9/26. The expired Pantoprazole remained available for use in the cart. Nurse #1 stated the medication had been overlooked and should have been removed from the cart and placed in the return-to-pharmacy bin in the medication room when the order was discontinued. Additional observations showed similar issues on other carts. The 100-hall medication cart contained a bag of ABH Gel syringes with 15 syringes remaining and a pharmacy expiration date of 6/1/26, although the physician’s order had been discontinued on 6/1/26. The 200-hall lower medication cart contained Propranolol 20 mg tablets with 25 pills remaining and a pharmacy expiration date of 11/30/25, although the order had been discontinued on 7/15/25. Staff interviews indicated that nurses and medication aides were expected to check expiration dates before administration, and that discontinued or expired medications should be removed from the carts and placed in the return-to-pharmacy bin, but these medications remained on the carts and available for use.
Failure to Request Level II PASRR for Resident With PTSD
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health diagnosis. Resident #90 was admitted with diagnoses that included PTSD, and the admission MDS identified PTSD as an active psychiatric/mood disorder diagnosis. A PASRR Determination Notification letter dated 7/21/25 showed the resident had a Level I PASRR with no expiration date, and the resident’s physician progress note dated 9/3/25 also documented PTSD in the resident’s health history. During interviews, the SW Assistant stated she was responsible for ensuring residents had PASRR determination letters and requesting evaluations as needed. She confirmed that when Resident #90 was admitted, a Level I PASRR determination letter had already been completed at the hospital and that PTSD was present on admission. After reviewing the Level I PASRR screening, she acknowledged that PTSD is a mental health diagnosis but stated that because the Level I PASRR had been done recently, the diagnosis did not trigger her to request a Level II PASRR evaluation. The Administrator stated that a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis should be done.
Failure to Request Level II PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to submit a request for a Level II PASRR reevaluation after a significant change in condition was identified for a resident previously determined to have a Level II PASRR. Resident #9 was admitted with diagnoses including schizoaffective disorder-bipolar type, moderate dementia with psychotic disturbance, and unspecified psychosis. The NC MUST inquiry dated 07/13/21 showed the resident had a Level II PASRR with no expiration date, and a significant change MDS assessment dated [DATE] identified the resident as having a serious mental illness and/or intellectual disability or other related conditions. The resident's active psychiatric and mood disorder diagnoses included psychotic disorder and schizophrenia, and she received antipsychotic medication during the MDS assessment period. Review of the medical record found no evidence that a request for a Level II PASRR reevaluation was submitted after the significant change MDS assessment. During interview, the SW Assistant stated she was responsible for submitting Level II PASRR reevaluation requests when needed, but believed a request was only required if the significant change directly related to the mental illness. She reported she did not submit a request because the resident's mental status did not change. The Administrator stated that requests for Level II PASRR reevaluations should be made when a resident had a significant change in condition per regulatory guidelines.
Failure to Promptly Remove and Return Discontinued Controlled Substances
Penalty
Summary
The facility failed to have effective systems in place for the prompt return of controlled narcotic medications to the pharmacy after a resident was discharged. Specifically, oxycodone-acetaminophen prescribed to a resident with dementia and kidney stones remained stored in the medication cart after the resident's discharge, rather than being removed and returned as required. During a monthly reconciliation, it was discovered that a blister card containing 30 tablets of the controlled substance, along with its declining count sheet, was missing from the medication cart. Additionally, discrepancies were noted in the declining count sheets, including a late entry by a nurse for a dose that was not documented in the Medication Administration Record (MAR) and could not be accounted for. The investigation revealed that the Director of Nursing (DON) had conducted an audit and made copies of all narcotic count sheets, identifying that the discharged resident still had two cards of oxycodone-acetaminophen on the cart. The following day, when the DON attempted to remove the medications, one card was missing. Interviews with nursing staff indicated inconsistent practices in counting and signing off on controlled substances, with one nurse unable to recall the count or explain a missing signature, and another nurse admitting to borrowing medication for another resident without proper documentation. The pharmacist consultant, who conducted monthly checks, had not previously identified any discrepancies or discontinued narcotics left on the carts. The facility's policy required nurses to inform the DON when a controlled narcotic was no longer needed, but this process was not followed. The failure to promptly remove and return discontinued or unneeded controlled substances resulted in the misappropriation of medication. The incident led to the involvement of law enforcement, drug testing of staff, and reporting to regulatory agencies. The deficiency was attributed to lapses in pharmacy services and medication handling procedures, specifically the lack of timely removal of controlled substances from medication carts after discharge or discontinuation.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to properly manage the disposal of garbage and refuse, as observed during a survey. Two of the three dumpsters had open lids, and one had an open side door. Additionally, two wheeled gray plastic garbage cans were improperly maintained; one lacked a lid and was half full of loose refuse, while the other, used for rock salt, had a grapefruit-sized hole in its side. These observations were made in the presence of the Dietary Manager, Maintenance Director, and Maintenance Assistant. Interviews with staff revealed a lack of awareness and responsibility regarding the maintenance of the dumpster area. The Dietary Manager was unaware that her department was responsible for this area and acknowledged the importance of keeping it clean and lids closed for pest control. The Maintenance Director confirmed that the waste management company emptied the dumpsters on specific days and emphasized the need for closed lids and doors. The Administrator later confirmed that the maintenance department was responsible for the dumpster area and reiterated the importance of cleanliness and closed lids for pest control.
Failure to Complete Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to complete a daily nurse staffing sheet for 50 out of 76 days during the period from January 1, 2025, to March 17, 2025. The review of records showed missing staffing sheets on specific dates across January, February, and March 2025. The Medical Records Clerk was responsible for completing and posting the daily nurse staffing sheet, but there was no plan in place for another staff member to take over this task when she was not working. Interviews with the Medical Records Clerk, the Director of Nursing, and the Administrator revealed that the absence of a backup plan led to the failure in completing the staffing sheets. The Administrator was unaware of the issue, and the Director of Nursing confirmed that no one else was assigned to complete the sheets in the clerk's absence. This lack of a contingency plan resulted in the deficiency noted by the surveyors.
Inadequate Supervision During Shower Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with dementia and impulsiveness during a shower, leading to a fall and subsequent injury. The resident was in an unlocked wheelchair in the shower room when the nurse aide turned her back to retrieve supplies from a linen cabinet. During this brief period, the resident stood up, lost balance, and fell, resulting in a right femoral neck fracture. This incident highlights a lapse in supervision, particularly given the resident's known history of impulsiveness and falls. The resident had a comprehensive care plan in place due to his extensive fall history, unsteady gait, and cognitive impairments. Despite these documented risks, the care plan interventions were not effectively implemented during the shower. The resident's care plan included measures such as ensuring the wheelchair was locked and providing substantial assistance during transfers, which were not adhered to at the time of the incident. Following the fall, the resident experienced significant complications, including acute blood loss anemia and swallowing difficulties, which required further medical intervention. The resident was eventually admitted to hospice care and passed away shortly after returning to the facility. Interviews with staff revealed a lack of awareness and adherence to the necessary precautions for residents at high risk of falls, contributing to the incident.
Removal Plan
- Nurse Aide #1 was educated by the Director of Nursing on ensuring that she does not turn away from the resident in the shower room while performing showering and bathing tasks.
- A 100% review of all falls occurring was conducted by the Director of Nursing and Assistant Director of Nursing to ensure there were no repeated patterns related to falls in the shower room.
- All residents identified as being at risk for falls will have care plan reviews conducted by the Director of Nursing and Assistant Director of Nursing to ensure that fall interventions are appropriate related to assistive devices and level of supervision.
- A root cause analysis was conducted by the Director of Nursing and Assistant Director of Nursing to determine the cause of the incident.
- An ad hoc QAPI meeting was held to review the root cause analysis and approve the proposed plan of correction.
- All nurse aides on the facility shower team were educated by the Director of Nursing on ensuring that staff do not turn away from the resident in the shower room while performing showering and bathing tasks.
- All facility nurse aides and licensed nurses were educated by the Director of Nursing on ensuring that staff do not turn away from the resident in the shower room while performing showering and bathing tasks.
- All facility nurse aides and licensed nurses will be educated in-person by the Administrator or Director of Nursing or trained designee on the facility fall management policy with an emphasis on ensuring assistive devices are in place and adequate supervision provided to prevent falls.
- The in-person education will be completed and any facility nurse aide or licensed nurse that does not receive the education will not be allowed to work until the education is received.
- Any newly hired nurse aide or licensed nurse will receive the education prior to working their first shift on the floor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 106 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hendersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Hendersonville | 0.6 mi | ★★★★★ | 5 | 0 |
| Carolina Village Inc | 0.7 mi | ★★★★★ | 0 | 0 |
| Orchard Valley Health And Rehabilitation | 2.4 mi | ★★★★★ | 14 | 0 |
| The Greens At Hendersonville | 2.4 mi | ★★★★★ | 2 | 0 |
| Valley Hill Health & Rehab Center | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Laurels Of Hendersonville.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.