Inspection Reports for The Gardens of Hendersonville
1000 West Allen Street Hendersonville, NC 28739, Hendersonville, NC, 28739
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 22, 2023
Visit Reason
The visit was a Construction Section Biennial Follow Up Survey conducted to assess compliance with physical plant and fire safety code requirements.
Findings
The facility failed to meet code requirements related to doors equipped with Special Locking and fire safety equipment. Specifically, the Special Locking System lacked a required diagram at the Fire Alarm Control Panel, and a door in the 100 Hall did not latch properly upon fire alarm activation, potentially affecting occupant safety.
Deficiencies (3)
Facility failed to meet code requirements for doors equipped with Special Locking, lacking all required components for proper operation.
Special Locking System does not have a diagram and system component location/map posted under glass at the Fire Alarm Control Panel.
Failure to maintain fire safety equipment in safe operating condition; door in 100 Hall did not latch when closed by fire alarm activation.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 19, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation with an onsite visit from 04/19/23 to 04/20/23, and a desk review on 04/21/23 with a telephone exit on 04/21/23.
Complaint Details
The visit included a complaint investigation and follow-up to a previously unabated Type B Violation related to medication administration.
Findings
The facility failed to administer medications as ordered to Resident #2, specifically failing to titrate gabapentin over a three-week period as prescribed, resulting in adverse side effects. Additionally, the facility failed to ensure medication aides observed residents taking medications, resulting in medications left unattended and not administered to Resident #1. The facility also failed to ensure that a medication aide met training and competency requirements within 60 days of hire.
Deficiencies (4)
Failed to administer gabapentin as ordered with titration over three weeks for Resident #2, resulting in dizziness and hand tremors.
Failed to observe Resident #1 take medications, resulting in medications left on bedside table and a pain patch not applied.
Failed to ensure electronic medication administration records were accurate; medications documented as administered when they were left unattended and pain patch not applied for Resident #1.
Failed to ensure medication aide (Staff A) passed required medication aide test within 60 days of hire.
Report Facts
Medication administration documented days: 31
Medication aide test timeframe: 60
Gabapentin dosage: 300
Inspection dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to pass medication aide test within 60 days and documented medication administration without passing test. |
| Resident Care Coordinator | Responsible for reviewing physician orders, notifying pharmacy, and approving medication orders. | |
| Area Clinical Director | Provided expectations for medication administration and documentation. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 1, 2023
Visit Reason
The Adult Care Licensure Section completed a follow-up survey on 02/01/23 and 02/02/23 to verify correction of previous deficiencies.
Findings
The facility failed to verify Health Care Personnel Registry checks for one staff member prior to employment and failed to administer a prescribed medication for one resident, which placed the resident at risk of cardiac problems. The medication administration deficiency was a follow-up to a previous Type B violation that was not abated.
Deficiencies (2)
Facility failed to verify there were no substantial findings on the Health Care Personnel Record for one of two sampled staff prior to working at the facility.
Facility failed to ensure a medication prescribed by a licensed prescriber was administered as ordered for one of five sampled residents related to a medication to treat low blood potassium.
Report Facts
Number of sampled staff with HCPR check issue: 1
Number of sampled residents with medication administration issue: 1
Number of sampled residents: 5
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 1, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on 11/01/22 - 11/02/22.
Complaint Details
The inspection included a complaint investigation as part of the annual survey.
Findings
The facility failed to ensure medications prescribed by a licensed prescriber were administered as ordered for 2 of 5 sampled residents related to a medication that treats high blood glucose and a medication for sleep. This failure put Resident #2 at risk of uncontrolled diabetic ketoacidosis and Resident #3 experienced lack of sleep and tiredness due to missed medication doses.
Deficiencies (2)
Failure to administer Novolog insulin as ordered for Resident #2, resulting in risk of uncontrolled diabetic ketoacidosis.
Failure to administer temazepam as ordered for Resident #3 due to medication supply and pharmacy issues, resulting in sleep disturbances.
Report Facts
Residents sampled: 5
Residents with medication administration issues: 2
Novolog insulin units: 44
Novolog insulin units: 38
Novolog insulin units: 48
Finger stick blood sugar range: 109
Finger stick blood sugar range: 343
Temazepam dosage: 7.5
Temazepam dosage: 15
Days temazepam not administered: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide Supervisor | Interviewed regarding medication administration and eMAR auditing responsibilities | |
| Executive Director (ED) | Interviewed regarding medication order processes and pharmacy communication | |
| Nurse Practitioner (NP) | Contracted NP for Residents #2 and #3, interviewed about medication orders and effects of missed doses | |
| Pharmacist | Contracted facility pharmacist interviewed about medication orders and pharmacy communication |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 22, 2019
Visit Reason
This was a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies related to physical plant requirements and building safety.
Findings
The facility failed to meet NC State Building Code requirements for special locking on exit doors, as the emergency release switches were momentary and did not unlock the doors as required. Additionally, the courtyard fence was damaged with a gate post broken off at the ground, making the fence structurally unsound.
Deficiencies (2)
Failed to meet NC State Building Code requirements for special locking (magnetic locks) on exit doors; emergency release switches were momentary and did not unlock doors as required.
Courtyard fence damaged and not maintained in a safe and operating condition; gate post broken off at the ground making fence structurally unsound.
Inspection Report
Capacity: 60
Deficiencies: 10
Date: Sep 26, 2019
Visit Reason
The inspection was a Construction Section Biennial Survey to assess compliance with the 1987 Minimum Standards and Regulations for Homes for the Aged and Disabled, the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1978 Edition of the North Carolina State Building Code.
Findings
The facility failed to meet multiple physical plant and safety requirements including non-functioning emergency release switches on magnetically locked exit doors, inadequate wanderer alarms, excessive dust accumulation in HVAC systems, unsafe storage of portable oxygen cylinders, incomplete fire safety rehearsals, malfunctioning fire alarm and emergency lighting systems, improper storage of combustible materials, and compromised fire-rated walls, doors, and ceilings.
Deficiencies (10)
Emergency release switches on magnetically locked exit doors did not work; toggle switches that did work were small and not known to senior staff.
Some special locking emergency exit switches were not protected by wander alarms, allowing potential resident elopement without warning.
Excessive accumulation of dust and lint on HVAC return grills and radiation dampers in multiple rooms.
Portable medical oxygen cylinders were stored freestanding without containers or racks, posing a hazard.
Fire drill rehearsals were not conducted regularly on each shift quarterly, and records lacked sufficient detail.
Fire alarm system was showing a 'Trouble' condition, potentially impairing proper operation.
Large quantities of combustible storage (about 150 cases of diapers and other combustibles) were kept in a former bedroom not designed as storage.
Battery powered emergency lights in corridor at Business office and Kitchen did not work when tested.
Corridor doors near room 102 did not close completely and latch; holes and disabled latches found on several doors.
Required one-hour fire rated walls and ceilings were compromised by holes, unsealed penetrations, and damaged areas in multiple locations including Nursing office and mechanical rooms.
Report Facts
Total licensed capacity: 60
Combustible storage quantity: 150
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 7, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 05/07/19 and 05/08/19 to verify correction of a previously cited Type B medication administration violation.
Findings
The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 1 of 5 sampled residents related to a medication ordered for sleep. Specifically, trazadone was not administered as ordered, and there was no documentation explaining the missed doses. The pharmacy had not received or dispensed the medication, and the Resident Care Coordinator was unaware of the discrepancy.
Deficiencies (1)
Failure to ensure medications were administered as ordered by a licensed prescribing practitioner for 1 of 5 sampled residents related to a medication ordered for sleep (trazadone).
Report Facts
Sampled residents: 5
Medication dosage: 25
Dates medication not administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for ensuring medications were on the MAR; unaware why medication aides documented administration of trazadone | |
| Regional Clinical Director | Interviewed regarding medication transcription and order faxing process | |
| Resident #3's Nurse Practitioner | Nurse Practitioner | Ordered trazadone for Resident #3 and provided clinical insight on medication administration |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 7, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey from 03/05/19 to 03/07/19 to assess compliance with health care, medication administration, infection control, and other regulatory requirements.
Findings
The facility failed to notify physicians about significant resident health changes, clarify conflicting medication orders, administer insulin as prescribed, and maintain proper infection control practices related to sharps container storage. These deficiencies posed risks to resident health and safety.
Deficiencies (4)
Failed to assure physician notification for Resident #4's significant weight gain and Resident #13's attendance at a scheduled follow-up appointment for hepatitis C treatment.
Failed to assure contact with prescribing physician for clarification of conflicting medication orders for Demadex (Resident #4) and Ativan (Resident #12).
Failed to assure insulin was administered as ordered for Resident #7, resulting in borrowing insulin from another resident and potential risk of hypoglycemia.
Failed to implement infection control policy consistent with CDC guidelines, resulting in unsecured sharps containers accessible to residents and spillage of contents.
Report Facts
Weight gain: 9
Medication doses: 3
Medication doses: 0.5
Insulin units: 48
Insulin units borrowed: 28
Medication doses administered: 11
Medication doses administered: 135
Medication doses dispensed: 97
Medication doses dispensed: 165
Medication doses dispensed: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for auditing MARs, notifying providers, and clarifying medication orders; involved in findings related to weight gain notification and medication order clarification. | |
| Administrator | Interviewed regarding lack of knowledge of resident weight gain, medication issues, and sharps container orders. | |
| Medication Aide | Involved in medication administration errors including failure to notify provider of weight gain, administering incorrect Demadex dose, borrowing insulin from another resident, and sharps container handling. | |
| Physician Assistant | Provided information on correct Demadex dosing and expectations for facility notification. | |
| Home Health Nurse | Noticed resident weight gain and contacted provider; identified medication dosing issues. | |
| Pharmacist | Provided details on medication dispensing and refill issues for Demadex and Ativan. | |
| Transport Manager | Responsible for scheduling and transporting residents to appointments; unaware of some scheduled appointments. | |
| Dietary Manager | Interviewed regarding therapeutic diet list inaccuracies. | |
| Executive Director | Interviewed regarding diet list updates, medication order clarifications, and sharps container orders. | |
| Corporate Director of Clinical Services | Interviewed regarding sharps container handling and facility policies. | |
| Licensed Health Professional Support Nurse | Provided information on insulin refill procedures and medication administration training. | |
| Nurse Practitioner | Provided clinical insight on insulin types and risks of medication borrowing. |
Inspection Report
Capacity: 60
Deficiencies: 10
Date: Jul 5, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey to ensure the facility meets applicable standards including the 1987 Minimum Standards and Regulations for Homes for the Aged and Disabled, 2005 Rules for Adult Care Home of Seven or More Beds, and the 1978 Edition of the North Carolina State Building Code.
Findings
The survey identified multiple deficiencies related to fire safety and physical plant conditions, including unresolved sprinkler system deficiencies, missing or outdated fire safety inspection reports, corridor obstructions, improper storage of oxygen cylinders, missing hardware on smoke barrier doors, inadequate fire drill rehearsals, malfunctioning emergency lighting, and compromised fire-rated walls and ceilings.
Deficiencies (10)
Water pressure switch not operational and failed to activate fire alarm system during system flow test.
Missing required annual fire alarm system inspection report.
Corridor was not maintained free of obstructions; path to exterior blocked by a chair (corrected during survey).
Improper handling and storage of portable medical oxygen cylinders in multiple locations.
Hasp and padlock on pantry door could trap someone inside.
Missing latch assembly on smoke barrier door exposing sharp edges.
Fire drill rehearsals not conducted regularly on all shifts each quarter; records lacked sufficient detail.
Many corridor doors prevented from closing and latching properly, including smoke barrier doors and double doors equipped with mechanical 'kick-downs'.
Battery powered emergency light in dining room would not work when tested.
One-hour fire rated walls and ceilings compromised by holes and penetrations not sealed with approved materials.
Report Facts
Total licensed capacity: 60
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 28, 2017
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services conducted a follow-up survey and complaint investigation on June 27-28, 2017, initiated by a complaint on June 1, 2017.
Complaint Details
Complaint investigation initiated by Henderson County Department of Social Services on June 1, 2017, leading to follow-up survey on June 27-28, 2017.
Findings
The facility failed to provide adequate personal care assistance related to incontinent care and showers for Residents #1, #3, and #6, and failed to ensure referral and follow-up for refusal of personal care and medication administration issues for Residents #3, #5, and #6. Medication administration was not in accordance with orders for Resident #5, including missing medications and lack of controlled substance records.
Deficiencies (4)
Failed to assure personal care assistance was provided concerning incontinent care and showers for Residents #1, #3, and #6.
Failed to assure referral and follow-up in the areas of refusal of personal care and failure to administer medications due to unavailability for Residents #3, #5, and #6.
Failed to assure medications were administered as ordered for Resident #5, including memantine, ranitidine, and DuoNeb.
Failed to maintain readily retrievable records for controlled substances for Resident #5, resulting in 30 missing lorazepam 0.5mg tablets.
Report Facts
Documented shower attempts for Resident #3: 7
Missing lorazepam tablets: 30
Medication administration not given: 15
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2017
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services conducted a follow-up survey and a complaint investigation on February 15-17, 2017, initiated by Henderson County Department of Social Services on January 17, 2017.
Complaint Details
Complaint investigation was initiated by Henderson County Department of Social Services on January 17, 2017, due to concerns about resident care including falls, medication availability, and lab testing.
Findings
The facility failed to maintain clean floor coverings in multiple common areas and failed to assure referral and follow-up to meet the routine and acute health care needs of residents, including failure to notify physicians and family after falls, failure to provide prescribed pain medication, and delayed lab testing. These failures resulted in harm to residents, including hospitalization and end-of-life care.
Deficiencies (3)
Facility failed to have floor coverings kept clean in common areas including hallways, living room, dining room entrance, and shower rooms.
Facility failed to assure referral and follow-up to meet routine and acute health care needs for 3 of 6 residents with changes in condition, falls with injury, medication not available, and lab tests not obtained as ordered.
Facility failed to assure residents received care and services that are adequate, appropriate, and in compliance with federal and state laws and rules related to health care.
Report Facts
Facility Sanitation Score: 97.8
Demerits: 1
Residents with unmet health care needs: 3
Morphine doses missed: 12
Ammonia lab delay: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Called physician office for morphine hard script refill |
| Staff B | Medication Aide | Assessed Resident #6 after fall and documented bruise |
| Executive Director | Aware of carpet condition and contacted carpet installers | |
| Maintenance Supervisor | Responsible for carpet cleaning and shower room maintenance | |
| Family Nurse Practitioner | FNP | Provided follow-up care for Resident #1 |
| Resident Care Coordinator | RCC | Involved in resident care coordination and family communication |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 18, 2016
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services conducted an annual and follow-up survey on November 16-18, 2016 to assess compliance with adult care home regulations.
Findings
The facility was found to have deficiencies including worn and stained carpeting in multiple common areas and shower rooms, and failure to notify the physician of elevated fingerstick blood sugar readings for one resident. Additionally, the facility failed to administer Novolog sliding scale insulin as ordered for one resident.
Deficiencies (4)
Facility failed to have floor coverings kept clean in multiple common areas and shower rooms.
Facility failed to notify the physician of elevated fingerstick blood sugar readings for Resident #1.
Facility failed to assure Resident #1 was administered Novolog sliding scale insulin as ordered.
Facility failed to assure residents received care and services that are adequate, appropriate, and in compliance with laws related to medication administration.
Report Facts
Total score: 97.8
Demerits deducted: 1
Funding applied for: 400000
FSBS readings range: 209
FSBS readings range: 486
FSBS readings range: 81
FSBS readings range: 502
FSBS readings range: 72
FSBS readings range: 385
FSBS readings range: 127
FSBS readings range: 499
Novolog insulin sliding scale administered correctly: 28
Novolog insulin sliding scale administered correctly: 78
Novolog insulin sliding scale administered correctly: 64
Novolog insulin sliding scale administered correctly: 38
Funding applied for: 400000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Observed administering Novolog insulin and performing fingerstick blood sugar testing for Resident #1 |
| Staff E | Medication Aide | Reported notifying supervisor of elevated blood sugar and administering sliding scale insulin |
| Staff A | Supervisor/Medication Aide | Responsible for notifying physician of elevated blood sugar and clarifying insulin orders |
| Resident #1's Nurse Practitioner | Provided orders for insulin and blood sugar monitoring, and verbal order to add sliding scale insulin at bedtime | |
| Resident #1's Endocrinologist | Provided orders for insulin and blood sugar monitoring; nurse interviewed regarding notification parameters | |
| Executive Director | Interviewed regarding facility policies and plans to address deficiencies | |
| Resident Care Coordinator | Responsible for reviewing doctor's orders and medication administration oversight | |
| Maintenance staff | Reported carpet cleaning and shower room maintenance procedures |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 16, 2015
Visit Reason
Follow-up survey conducted to verify correction of a previously cited deficiency related to emergency exiting and building code compliance.
Findings
The facility failed to correct the deficiency regarding emergency release buttons for magnetic locks at all exits; the momentary release buttons still allow doors to re-lock after approximately 30 seconds.
Deficiencies (1)
The emergency release buttons for the magnetic locks located at all exits are momentary release buttons, allowing the doors to re-lock after approximately 30 seconds.
Report Facts
Time before doors re-lock: 30
Inspection Report
Follow-Up
Deficiencies: 3
Date: Oct 29, 2015
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies at Cardinal Care Center-Hendersonville.
Findings
The facility failed to correct several deficiencies related to physical plant safety, including emergency exit compliance, lack of wanderer alarm systems on exit doors, and fire safety issues such as unprotected penetrations and malfunctioning smoke doors.
Deficiencies (3)
Facility failed to ensure building meets NC State Building Code regarding emergency exiting; emergency release buttons on magnetic locks re-lock after approximately 30 seconds.
Facility failed to have a system for monitoring all exit doors with sounding devices as required for residents who are disoriented or wanderers; two exit doors to secure courtyard are unlocked and lack sounding devices.
Facility failed to maintain fire resistance of building components; unprotected penetrations in mechanical room and smoke doors at Room 102 do not completely close and latch.
Inspection Report
Capacity: 60
Deficiencies: 7
Date: Aug 12, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 1987 Minimum Standards and Regulations for Homes for the Aged and Disabled, applicable adult care home rules, and the North Carolina State Building Code.
Findings
The facility failed to meet multiple physical plant and safety requirements including emergency exit compliance, lack of wanderer alarm systems, poor housekeeping with dust accumulation, hazards from doors being wedged open, and fire safety system deficiencies such as non-functional exit signs on battery power and unprotected penetrations compromising fire resistance.
Deficiencies (7)
Emergency release buttons for magnetic locks at all exits are momentary and re-lock after approximately 30 seconds.
Facility failed to have a system for monitoring all exit doors with sounding devices as required for disoriented residents.
HVAC returns and exhaust fans throughout the facility have large amounts of dust and lint accumulated on grill vents and radiation dampers.
Doors in multiple locations are held open with wedges or chairs, preventing proper closing in emergencies.
Fire safety systems are not maintained safe and operating; exit signs in kitchen and living room do not work on battery power.
Unprotected penetrations exist around gas piping, stove fire suppression piping, ceiling and walls of Med Room, mechanical room, and laundry room.
Smoke doors at Room 102 do not completely close and latch.
Report Facts
Licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 20, 2015
Visit Reason
The Adult Care Licensure Section and the Henderson County Department of Social Services conducted an annual survey, follow-up survey, and complaint investigation on February 18, 19, and 20, 2015.
Complaint Details
Complaint investigation was triggered by a complaint alleging the facility charged Resident #6 a private rate on top of the State-County Special Assistance rate and was unwilling to reimburse approximately $20,000 overcharged.
Findings
The facility was found deficient in correctly charging room rental rates related to State-County Special Assistance for one resident, and failed to assure proper administration of Humalog sliding scale insulin medication for two residents. Additionally, the facility failed to ensure that two residents with restraint orders were checked every 30 minutes and released every 2 hours and at mealtimes as ordered by the physician.
Deficiencies (3)
Failed to ensure correct room rental rate charged for Resident #6 related to State-County Special Assistance.
Failed to assure 2 of 3 sampled residents were administered Humalog sliding scale insulin as ordered by the physician (Residents #5 and #7).
Failed to assure 2 of 2 sampled residents with restraint orders (Residents #2 and #4) were checked every 30 minutes and released every 2 hours and at mealtimes as ordered by the physician.
Report Facts
Room rental rate: 1900
Room rental rate increase: 2054.85
Humalog insulin doses: 8
Humalog insulin doses: 10
Humalog insulin administration opportunities: 6
Correct administrations: 4
Humalog insulin administration opportunities: 64
Correct administrations: 49
Humalog insulin administration opportunities: 36
Correct administrations: 25
Humalog insulin administration opportunities: 78
Correct administrations: 66
Humalog insulin administration opportunities: 61
Correct administrations: 59
Humalog insulin administration opportunities: 100
Correct administrations: 91
Restraint recertification dates: 9
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