A list of the most recent deficiencies for The Laurels of Hendersonville. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-04-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-07 | 2024-03-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-03-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-20 | 2024-01-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-20 | 2024-01-20 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-05 | 2024-01-20 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-05 | 2024-01-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-05 | 2024-01-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-05 | 2024-01-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-05 | 2024-01-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-05 | 2024-01-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-05 | 2024-01-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-05 | 2024-01-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-05 | 2024-01-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-01-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-20 | 2024-01-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-20 | 2024-01-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-01-05 | 2023-11-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-01 | 2023-08-21 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-22 | 2022-07-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-22 | 2022-07-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-22 | 2022-07-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-22 | 2022-07-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-22 | 2022-07-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-22 | 2022-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-22 | 2022-07-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-30 | 2021-07-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-05 | 2020-04-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-03-05 | 2020-04-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-04-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-05 | 2020-04-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-03-05 | 2020-04-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-05 | 2020-04-01 | N |
