Terrabella Hendersonville

The facility failed to provide required personal care assistance for a resident who needed help with showers. Although the resident's care plan and room schedule required showers twice weekly, the resident was only assisted once weekly, and documentation failed to show consistent care or recorded refusals.

The facility failed to provide required personal care assistance for a resident who needed help with showers. Specifically, Resident #8 did not receive a scheduled shower on 04/08/25, and there was a lack of documentation regarding shower assistance or refusals. Staff were unable to confirm if the resident was receiving the required twice-weekly showers as outlined in the care plan.

The facility failed to provide adequate supervision for two residents with a history of falls. No additional safety interventions were ordered or implemented to minimize the risk of future falls for these individuals.

The facility failed to respond immediately to an incident involving a resident. Specifically, staff discovered Resident #4's bathroom door was locked and the resident could not be located, indicating a failure to provide necessary care and intervention per policy.

The facility failed to respond immediately to an incident involving a resident. Specifically, staff were unable to locate Resident #4 because their bathroom door was locked and the resident was missing from their expected location.

The facility failed to ensure that 3 out of 6 sampled residents had an accurate care plan signed and dated by a physician within 15 days of the assessment completion. Specifically, for Resident #6, the care plan lacked the required physician signature despite documented changes in orientation and wandering behaviors.

The facility failed to ensure resident care plans were properly maintained and physician-signed. Specifically, Resident #6's care plans lacked physician signatures, and the facility used an unapproved 'Service Plan' in place of the required care plan. Additionally, staff relied on verbal communication rather than documented care plans to determine the level of assistance needed for activities of daily living.

The facility failed to administer medications as ordered for one resident, specifically failing to provide metoprolol prescribed for elevated heart rate. This occurred because the facility did not obtain the necessary refill authorization from the resident's primary care physician, leading to an exhausted supply. Consequently, the resident missed multiple doses of the medication between January 8 and January 10, 2022.