Biltmore Haven Nursing and Rehabilitation

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of range of motion, dental, Preadmission Screening and Resident Review (PASRR), physical restraints, and active diagnoses for 5 of 36 assessments reviewed for MDS accuracy (Residents #4, #13, #49, #50, and #59).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment no later than 14 calendar days of the Assessment Reference Date (ARD, referring to the last day of the assessment period) for 1 of 36 sampled residents (Residents #13).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide showers as scheduled to a resident dependent on staff assistance for bathing for 1 of 6 residents reviewed for activities of daily living (Resident #13).

Inspectors wroteBased on observations, record reviews, and Nurse Practitioner (NP), staff, and resident interviews, the facility failed to follow physician order for referral to Gastrologist for routine endoscopy (procedure to examine esophagus, stomach, and upper part of small intestine) and colonoscopy (procedure to examine large intestine and rectum). These practices occurred for 1 of 3 residents reviewed for care to maintain wellbeing (Resident #57).

Inspectors wroteBased on observations, record reviews, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to follow through with the eye physician's recommendations for an Ophthalmology consult for cataract surgery. This practice occurred for 1 of 1 resident reviewed for care and treatment to maintain vision (Resident #57).

Inspectors wroteBased on observations, record review, residents, staff, and Nurse Practitioner (NP) interviews, the facility failed to ensure resident's toenails were trimmed and podiatry services were arranged for 3 of 3 residents reviewed for foot care (Resident #34, Resident #44, and Resident #65).

Inspectors wroteBased on observations, record reviews, and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 2 resident reviewed for respiratory care (Resident #73).

Inspectors wroteBased on record review and staff interviews, the facility failed to document a resident's discharge from the facility, ensure nurse assessments were accurately documented in the electronic medical record and ensure medications were accurately documented on the medication administration record for 1 of 5 discharged residents reviewed for complete and accurate medical records (Resident #81).

Inspectors wroteBased on record review, resident, staff, Nurse Practitioner and Medical Director interviews, Driver #1 failed to have Resident #1 assessed for injury by a qualified medical professional prior to moving the resident following a fall in the transportation van. Resident #1's wheelchair tipped over backwards with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. Driver #1 lifted Resident #1 while in his wheelchair back to the upright position and returned to the facility without calling Emergency Medical Services for assistance. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if Resident #1 had sustained any injuries. [...]

Inspectors wroteBased on observations, record review and interviews with resident, staff, Nurse Practitioner and Medical Director, Driver #1 failed to provide safe transportation on 03/02/2026 when Resident #1's lap belt and front retractor tie-downs (retractor tie-down systems are often called a 4-point securement system) were not correctly applied per manufacturer's instructions leaving Resident #1 not fully secured while in his wheelchair in the facility transport van. Resident #1, who only had one leg, and no hands, was being transported to a medical appointment by Driver #1. As the vehicle accelerated from a full stop at a traffic light, Resident #1's wheelchair tipped over backward with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 1: October 1-December 31, 2024).

Inspectors wroteBased on record review and interviews with the Law Enforcement Detective and staff, the facility failed to protect the residents' rights to be free from misappropriation of controlled medication for 4 of 4 residents reviewed for misappropriation of resident property (Residents #173, #174, #175, and #176).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to record opened dates on multi-dose oral inhalers and label and date opened multi-dose bottles of eye drops on 3 of 4 medication carts (400 Hall, 200 Hall, and 300 Hall) reviewed for medication storage.

Inspectors wroteBased on record review, observations and interviews with staff, the facility failed to follow the meal spreadsheet and posted menu when they ran out of a food item while plating meals. This deficient practice impacted 7-9 residents who did not receive regular consistency carrots for their lunch meal.

Inspectors wroteBased on observations and staff interviews the facility failed to remove food stored past the use by date from the dry goods storage area. Additionally, the facility failed to clean a circulatory fan cover and prevent water from dripping onto stored food in 1 of 2 kitchen refrigerators (the walk-in refrigerator). This practice had the potential affect food served to residents.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to reschedule and hold a care plan meeting that was previously cancelled and invite the resident to participate in the care planning process for 1 of 1 sampled resident (Resident #43).

Inspectors wroteBased on observations, record reviews, staff and resident interviews, the facility failed to assess residents for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #59).

Inspectors wroteBased on record review and resident, Family Member and staff interviews, the facility failed to have a discharge planning process in place that included documentation of referrals submitted to other skilled nursing facilities (SNF) and documenting the responses to the referrals submitted for a resident who wished to discharge to another SNF closer to family for 1 of 1 sampled resident (Resident #41).

Inspectors wrote2. Resident #19 was admitted on [DATE] and re-admitted on [DATE]. Resident #19's diagnoses included paranoid schizophrenia that was present on admission [DATE]). Resident #19 was care planned for receiving antipsychotic therapy (haloperidol) for diagnosis of paranoid schizophrenia dated 10/28/24. Resident #19's annual Minimum Data Set (MDS) assessment dated [DATE] included an active diagnosis of schizophrenia. A review of Resident #19's physician orders revealed an order for haloperidol 0.5 milligrams 2 times daily for diagnosis of paranoid schizophrenia dated 3/14/25. Resident #19's quarterly Minimal Data Set (MDS) assessment dated [DATE] did not include an active diagnoses of schizophrenia. On 5/01/25 at 11:57 AM the MDS Nurse stated Resident #19 was readmitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a baseline care plan that addressed the resident's immediate needs within 48 hours of admission for 4 of 13 sampled residents (Residents #73, #16, #72, and #323).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to perform activities of daily living (ADL) care for a resident (Resident #30). This was for 1 of 11 residents reviewed for (ADL) care.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen and ensure the physician order included the oxygen flow rate (amount of oxygen administered in liters per minute) and delivery method (nasal cannula) for 1 of 1 resident reviewed for respiratory care (Resident #73).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to assess a resident for risk of entrapment prior to installing and/or using bed rails for 1 of 4 sampled residents reviewed for accidents (Resident #18). Findings Included: Resident #18 was admitted to the facility on [DATE]. Her cumulative diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebrovascular disease (conditions that affect blood flow to the brain) affecting the left dominant side, left knee contracture and chronic pain. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. She had impairment on one side of the lower extremity, was dependent on staff for assistance with bed mobility and did not use bed rails during the MDS assessment look-back period. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to have a system in place to ensure Nurse Aides (NA) were able to demonstrate the competency and skills necessary for providing care to meet the individual care needs of residents' that included hand hygiene during incontinence care for 3 of 5 employee files reviewed (NA #2, NA #3 and NA #4). On 04/30/25, NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment after providing incontinent care to a dependent resident.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain complete and accurate medical records by not documenting when residents admitted to the facility, discharged from the facility or expired at the facility for 3 of 23 sampled residents (Residents #73, #71, and #72).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse Aide (NA) #3 did not don (put on) a gown while providing urinary catheter (a tube that drains urine out of the body) care to Resident #65 who required enhanced barrier precautions (EBP) and failed to follow their Hand Hygiene policy when NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #65. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (NA #3).

Inspectors wroteBased on observations and staff interviews, the facility failed to label and store personal items in 2 of 6 shared bathrooms (room [ROOM NUMBER] and room [ROOM NUMBER]) and maintain packaged terminal air conditioners (PTACs) in good repair in 6 of 15 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). These failures occurred on 1 of 4 halls (400 hall) reviewed for home-like environment.

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to: 1) maintain a clean and sanitary kitchen; 2) failed to remove gloves and perform hand hygiene after handling dirty dishes; 3) failed to date opened food items stored in the walk-in refrigerator ready for use; 4) failed to discard thickened juice by the date it could no longer be used; and 5) failed to seal and date an open bag of cereal for 1 of 1 kitchen. These practices had the potential to affect ninety-one (91) residents who resided in the facility.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to ensure a resident's toenails were trimmed for 1 of 3 sampled residents (Resident #1).

Inspectors wroteBased on record review, observations, and interviews with staff the facility failed to store an unopened insulin pen in the refrigerator until needed for use for 1 of 4 medication carts (200/300 Hall medication cart) and failed to remove medicated mouthwash by the date it was to be discarded from 1 of 1 medication refrigerator reviewed for medication storage.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on [DATE]. This was for a repeat deficiency in the area of label/store drugs and biologicals that was originally cited during the recertification survey completed on [DATE] and subsequently recited during the revisit and complaint investigation completed on [DATE]. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on record review and staff, Responsible Party (RP), and Medical Director interviews the facility failed to notify the Responsible Party of a new diagnosis of pneumonia for 1 of 1 resident reviewed for notification of change (Resident #1).

Inspectors wroteBased on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. This deficient practice had the high likelihood of serious adverse outcome for 10 residents with history of substance abuse which included Resident #52. Immediate jeopardy started on 12/28/23 when the facility failed to follow their abuse policy and protect all residents with a history of substance abuse including Resident #52 by not suspending NA #1 after Resident #52 alleged that NA #1 had been supplying her with methamphetamine and syringes at the facility. [...]

Inspectors wroteBased on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. [...]

Inspectors wroteBased on record review, observation, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to provide effective leadership and implement effective systems to manage and supervise a resident with a history of substance abuse after syringes were found in Resident #52's room and protect all residents after Resident #52 reported Nurse Aide #1 was providing her with methamphetamine and syringes. This failure had a high likelihood of affecting other facility residents. Immediate jeopardy started on 10/5/23 when after observing drug paraphernalia in Resident #52's room the facility's administrative team failed to identify the seriousness of the situation and put effective systems in place. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. [...]

Inspectors wroteBased on record review, resident and staff interviews the facility failed to obtain dental services when ordered by the medical provider for 1 of 1 resident reviewed for dental services (Resident #52).

Inspectors wroteBased on record review and interviews with staff, Nurse Practitioners and the Medical Director, the facility failed to have systems in place to prevent a delay in obtaining mental health services for 1 of 3 residents reviewed for behavioral and emotional status (Resident #19).

Inspectors wroteBased on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to ensure physician's orders for as needed (PRN) psychotropic drug (drug that affects mental state) was time limited in duration and provided rationales for therapy exceeding 14 days for 1 of 5 sampled residents reviewed for unnecessary medications (Residents #61).

Inspectors wroteBased on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to prevent a significant medication error when nursing staff failed to follow physician's parameter as ordered during insulin and blood pressure medication administration. As a result, Resident #61 had received 6 doses of unnecessary Novolin insulin and 4 doses of blood pressure medication within 24 days. This affected 1 of 5 residents reviewed for unnecessary medications (Resident #61).

Inspectors wroteBased on observation, staff interviews, and record reviews, the facility failed to secure an opened tube of antifungal cream for 1 of 1 Resident (Resident #61) reviewed for medication storage, failed to record opening date for 3 opened insulin pens in 1 of 4 medication carts (500 Hall medication cart), and failed to remove expired over the counter (OTC) medications in accordance with the manufacturer's expiration date for 1 of 4 medication carts (500 Hall medication cart) and 1 of 1 medication room observed during medication storage checks (Main medication room).

Inspectors wroteBased on observation, and resident and staff interviews, the facility failed to provide snacks for 7 out of 7 residents that requested bedtime snacks (Resident #67, #34, #65, #5, #10, #60, #74).

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on 06/24/22 and the complaint investigation survey conducted on 05/03/23. This was for a repeat deficiency in the area of accident hazards/supervision/devices that was originally cited on 06/24/22 during the recertification survey, and subsequently recited during the complaint investigation survey completed on 05/03/23, and recertification survey completed on 01/16/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide behavioral health training that included the competencies and skills necessary to provide care for residents with substance use disorder for 9 of 9 nursing staff (Nurse Aide #3, Nurse Aide #6, Nurse Aide #5, Nurse Aide #7, Nurse Aide #9, Nurse Aide #10, Nurse Aide #8, Nurse #3 and Unit Manager) reviewed for education requirements.

Inspectors wroteBased on record reviews and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to have accurate advanced directive information documented throughout the medical record for 1 of 5 residents reviewed for code status (Resident #81).

Inspectors wroteBased on record reviews, and staff interviews, the facility failed to develop and implement an individualized person-centered care plan that addressed substance use disorder for 1 of 3 sampled residents with a known history of substance abuse (Resident #52).

Inspectors wroteBased on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities related to the use of as needed (PRN) psychotropic drug (drug that affects mental state) and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #61).

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on 6/24/22 and the complaint investigation survey conducted on 5/3/23. This was for a repeat deficiency in the area of infection control that was originally cited on 6/24/22 during the recertification survey, and subsequently recited during the complaint investigation surveys completed on 5/3/23 and 12/28/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing a soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 3 wound care observations on 2 of 2 residents reviewed (Resident #2 and Resident #3).