The Gardens of Hendersonville

The facility failed to properly administer a medication used for pain control for one resident. Specifically, the facility failed to follow a physician's order to titrate the dose of gabapentin over a three-week period.

The facility failed to correctly administer and document a medication titration for a resident. Specifically, a physician's order for gabapentin required a gradual dosage increase over three weeks, but the electronic Medication Administration Record (eMAR) showed the medication was administered at a fixed dose without the required titration. This resulted in a failure to follow the prescribed medication schedule for the resident.

The facility failed to verify that a staff member had no substantial findings on the Health Care Personnel Registry (HCPR) prior to being hired. A review of a medication aide's personnel record showed no documentation of an HCPR check was completed at the time of hire.

The facility failed to ensure that a medication prescribed by a licensed prescriber was administered as ordered. This finding represents a failure to abate a previous Type B violation.

The facility failed to verify that there were no substantial findings on the Health Care Personnel Registry (HCPR) for one of two sampled staff members prior to them working at the facility. A review of a medication aide's personnel record showed no documentation of an HCPR check was completed upon hire.

The facility failed to ensure that a prescribed medication was administered as ordered for one resident. Specifically, there was no documentation of potassium chloride administration in the electronic Medication Administration Records (eMAR) from December 17, 2022, to February 1, 2023, despite physician orders for the medication.

The facility failed to ensure medications prescribed by a licensed prescriber were administered as ordered for 2 of 5 sampled residents. Specifically, for Resident #2, there was no documentation that the increased dose of Novolog (48 units) was administered between 10/26/22 and 11/01/22, and there was no documentation that the evening dose of Novolog was administered from 10/26/22 to 10/31/22.

The facility failed to ensure that medications prescribed by a licensed prescriber were administered as ordered for two residents. Specifically, a change in Novolog dosage for Resident #2 was not updated on the electronic Medication Administration Record (eMAR), and the medication was not properly documented or implemented following the new order.

The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner for one resident. Specifically, a physician's order for trazadone was not properly maintained on the Medication Administration Record (MAR) for May 2019, and there was no documentation explaining why the medication was missed on certain dates in April 2019.

The facility failed to ensure physician notification for a resident regarding weight gain and failed to ensure a resident attended a scheduled follow-up appointment for lab monitoring. Specifically, there was no documentation that the provider was contacted regarding a resident's weight increase of several pounds, and a medication aide was unaware of the physician's order to notify the provider.