The Laurels of Hendersonville

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired and discontinued medications from 3 of 5 medication carts reviewed for medication storage (100 hall cart, 200 hall upper medication cart, and 200 hall lower medication cart).a. An observation on 6/5/26 at 10:14 AM with the Director of Nursing (DON) of the 200-hall upper medication cart revealed a medication card of Pantoprazole 40 milligram (mg) tablets that had a total of 27 pills left marked with an expiration date of 5/31/26 from the pharmacy. Review of the physician's order for Pantoprazole revealed that it had been discontinued on 3/9/26. Pantoprazole is used to treat gastroesophageal reflux disease (a condition that causes excess stomach acid). The expired Pantoprazole card was left available for use in the 200-hall upper medication cart. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for a Level II PASRR (Preadmission Screening and Resident Review) evaluation for a resident admitted with a serious mental health diagnosis for 1 of 2 residents reviewed for PASRR (Resident #90).

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) reevaluation after a significant change in physical or mental status was identified for a resident previously determined to have a Level II PASRR. This deficient practice affected 1 of 2 sampled residents reviewed for PASRR (Resident #9).

Inspectors wroteBased on observations, record review, interviews with the Pharmacist Consultant and staff, the facility failed to have effective systems in place for returning controlled narcotic medications (oxycodone-acetaminophen) to the pharmacy after a resident was discharged . The oxycodone-acetaminophen continued to be stored in the medication cart after the resident's discharge and during the monthly reconciliation of controlled substances misappropriation was identified. This occurred for 1 of 3 residents reviewed for pharmacy services (Resident #1).

Inspectors wroteBased on observations and staff interviews, the facility failed to keep dumpster doors and lids closed for 2 of 3 dumpsters observed and have a lid on one plastic garbage can and maintain another plastic garbage can in good condition for 2 of 2 garbage cans observed.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a daily nurse staffing sheet for 50 of 76 days for the period reviewed from January 1, 2025 through March 17, 2025.

Inspectors wroteBased on record review, and interviews with staff, Medical Director, and Medical Examiner, the facility failed to ensure Resident #1 was supervised during a shower. On 11/18/24 Nurse Aide (NA) #1 had Resident #1, who had dementia and impulsiveness, in the shower room in his unlocked wheelchair. Resident #1 removed his shoes and was removing his shirt when NA #1 turned her back and stepped away from Resident #1 to go to a linen cabinet. When NA #1 turned around, Resident #1 stood up from his wheelchair, lost his balance and fell. Resident #1 immediately verbalized pain. He was transferred to the Emergency Department (ED) and was diagnosed with a right femoral neck (thigh bone) fracture that required surgical repair. Resident #1 experienced acute blood loss anemia after surgery that required a blood transfusion and developed swallowing difficulties. He returned to the facility on [DATE]. [...]

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during Resident Council meetings for 6 of 7 months reviewed (June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain clean overbed tables (room [ROOM NUMBER]); maintain clean ceiling vents (bathroom of 104, 107, 112); maintain walls in good repair (rooms 104, 107, 205, and 207); maintain clean privacy curtains (rooms 106, 107, 112 and 205); maintain a clean bedside commode (shared bathroom of 107); and maintain a clean mechanical lift (lift for 100 and 200 halls) for 2 of 4 halls reviewed for environment (100 hall and 200 hall).

Inspectors wroteBased on record reviews, staff and Physician interviews the facility failed to follow a Physician's order for 1 of 1 resident (Resident #13).

Inspectors wroteBased on observations, record review, and interviews the facility failed to secure medications stored at the bedside for 3 of 3 residents (Resident #20, Resident #42, and Resident #8) reviewed for medication storage.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to assess residents to determine if self-administration of medication was clinically appropriate for a resident who wanted to self-administer over-the-counter lubricating eye drops and had a physician order indicating the eye drops may be left at bedside and a resident observed with medicated cream left on a shelf in the resident's room for 2 of 3 sampled residents (Resident #66 and #55).

Inspectors wroteBased on record review and staff interviews the facility failed to protect residents' rights to be free from misappropriation of narcotic pain medication for 2 of 2 residents (Resident #94 and Resident #96) reviewed for misappropriation of resident property.

Inspectors wroteBased on record review and staff, Consultant Pharmacist, and Medical Director interviews, the facility failed to follow up on the monthly pharmacist consultation reports for 1 of 4 residents reviewed for unnecessary medications for Resident #38.

Inspectors wroteBased on observations, interviews with staff, and record review the facility failed to maintain a medication error rate of 5% or less as evidenced by 2 medication errors out of 32 opportunities (Resident #51).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a medication administration record was accurate (Resident #51) and failed to maintain complete and accurate medical records by not documenting a resident's discharge to the community Against Medical Advice (Resident #90) and a resident's transfer to the hospital (Resident #95) for 3 of 6 sampled residents reviewed for medication pass and closed record review.

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 06/22/22, complaint investigation survey completed on 08/01/23, and the complaint investigation survey completed on 11/20/23. This was for three repeat deficiencies: one in the area of infection control originally cited on 06/22/22 during a recertification survey, one in the area of resident records-identifiable information originally cited on 06/22/22 during the recertification survey, and one in the area of residents right to self-administer medications originally cited on 08/01/23 during a complaint investigation survey. [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement their infection control policies and procedures when Nurse Aide (NA #3) did not handle soiled linen in a sanitary manner and did not perform hand hygiene after removing gloves for 1 of 1 room (room [ROOM NUMBER]) observed for infection control.

Inspectors wroteBased on observations, record review, and resident, family, staff, Physician Assistant, Guardian, Pastor, Psychiatric Nurse Practitioner, Psychotherapist, Law Enforcement, and Health Care Personnel Investigator interviews, the facility failed to protect a vulnerable female resident (Resident #1) from inappropriate sexual advances from an employee (Med Aide #1) for 1 of 3 residents reviewed for abuse. On 10/19/23, Resident #1 alleged Med Aide #1 had kissed her, touched her legs and breasts and exposed his penis to her which also had the high likelihood of placing other vulnerable residents at risk of abuse. Immediate Jeopardy began on 10/17/23 when Resident #1, who had moderate impairment in cognition, disclosed to her Family Member and Pastor that she was in a relationship with an employee at the facility and he had kissed her, touched her legs and breasts and exposed his penis to her. [...]

Inspectors wroteBased on facility record review and staff interviews, the facility failed to implement their abuse policy and procedures in the areas of screening and protection by not: 1) screening an employee prior to him transferring from a sister facility (Med Aide #1) and 2) protecting a vulnerable female resident (Resident #1) from inappropriate sexual advances from an employee (Med Aide #1) for 1 of 3 residents reviewed for abuse.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for the administration of vaginal cream for 1 of 1 resident reviewed (Resident #1).

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 and complaint investigation survey completed on 06/22/22. This was for one repeat deficiency in the area of resident records originally cited on 06/22/22 during a recertification and complaint investigation survey and subsequently recited on 11/20/23 during the complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.