Hendersonville Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hendersonville Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF756Jun 16, 2023

  Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders dated 05/31/23 revealed Resident #34 had an order to receive 10 units of Basaglar insulin subcutaneously once daily at bedtime for diabetes. The order specified to hold the insulin when Resident #34's capillary blood glucose (CBG) was lower than 150 milligrams per deciliter (mg/dL). […]

• No harm, potential for more than minimal, patternF760Jun 16, 2023

  Based 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 nurses failed to follow physician's parameter as ordered during insulin administration. As a result, Resident #34 received 10 doses of unnecessary Basaglar insulin within 15 days. This affected 1 of 5 residents reviewed for unnecessary medications (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders dated 05/31/23 revealed Resident #34 had an order to receive 10 units of Basaglar insulin subcutaneously once daily at bedtime for diabetes. […]

• No harm, potential for more than minimal, patternF584Oct 14, 2021

  Based on observations and staff interviews the facility failed to maintain the base of a toilet in sanitary condition for 1 of 15 rooms (Room #302), maintain a bedside commode in good condition for 1 of 3 bedside commodes (Room #302), maintain doors in good condition for 2 of 15 rooms (Room #309 and Room #310), and maintain wheelchair brakes in sanitary condition for 1 of 13 wheelchairs (Wheelchair #1) reviewed for a safe, clean, comfortable, and homelike environment. Findings included: 1. An observation of the bathroom of Room #302 on 10/11/21 at 10:21 PM revealed a black substance that was easily removable at the base of the toilet and the front metal bar of a beside commode that was sitting over the toilet had an area of rust to the front bar. […]

• No harm, potential for more than minimal, patternF812Oct 14, 2021

  Based on observations, record review, and staff interviews, the facility failed to remove expired food stored ready for use in 1 of 1 walk-in refrigerator, and ensure staff had all hair covered during food production which had the potential to cause cross-contamination of food served to residents in 2 of 6 dietary staff. Findings included: 1. An observation in the walk-in refrigerator on [DATE] at 9:39 AM revealed a sealed plastic bag of sliced onions dated [DATE]. The sliced onions showed signs of spoilage that included discoloration, a fluid coating, and foul odor. Signage titled Refrigeration Date Storage Chart posted on the outside door of the walk-in refrigerator and observed on [DATE] at 9:39 AM stated, cut or prepared vegetables should be used or discarded in 7 days. […]

• No harm, potential for more than minimal, isolatedF554Sep 11, 2024

  Based on observations, record review, and staff interviews the facility failed to assess the ability of a resident to self-administer medication for 1 of 1 resident with medication observed in the room (Resident #84). Findings included: Resident #84 was admitted to the facility 08/07/24. Review of the medical record revealed no documentation that Resident #84 was assessed for self-administration of medications. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was moderately cognitively impaired. […]