The Laurels Of Hendersonville
The Laurels of Hendersonville in Hendersonville, NC — inspection on June 5, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(Preadmission Screening and Resident Review) evaluation for a resident admitted with a serious
PASRR Determination Notification letter dated 7/21/25 revealed Resident #90 had a Level I PASRR with no expiration date.Resident #90 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD).Review of a physician's progress note dated 9/3/25 included a review of Resident #90's health history and noted a diagnosis of PTSD.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. PTSD was listed as an active psychiatric/mood disorder diagnosis.
During an interview on 06/03/26 at 9:18 AM and 06/05/26 at 10:01 AM, the Social Worker (SW) Assistant confirmed she was responsible for ensuring residents had a PASRR determination letter and she requested evaluations as needed.
She stated when Resident #90 was admitted , a Level I PASRR determination letter had already been done at the hospital on 7/21/25.
She confirmed Resident #90 diagnosis of PTSD was present when admitted on [DATE].
After review of Resident #90's Level I PASRR screening, the SW Assistant confirmed there was no mental health diagnoses identified on the screening done on 7/21/25.
She acknowledged PTSD was a mental health diagnosis and stated because the Level I PASRR was recently done, Resident #90's diagnosis of PTSD did not trigger her to request a Level II PASRR evaluation.
During an interview on 06/05/26 at 4:40 PM, the Administrator stated a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis should be done.
345322 06/05/2026
The Laurels of Hendersonville 290 Clear Creek Road Hendersonville, NC 28792
condition.
record review and staff interviews, the facility failed to submit a request for a Level II Preadmission
status was identified for a resident previously determined to have a Level II PASRR.
This deficient practice affected 1 of 2 sampled residents reviewed for PASRR (Resident #9).Findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder-bipolar type, dementia-moderate with psychotic disturbance, and unspecified psychosis.The North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) inquiry dated 07/13/21 revealed Resident #9 had a Level II PASRR with no expiration date. A significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Resident #9's active psychiatric/mood disorder diagnoses included psychotic disorder and schizophrenia.
She received antipsychotic medication during the MDS assessment period.Review of Resident #9's medical record revealed no evidence a request for a Level II PASRR reevaluation was submitted following the significant change MDS assessment dated [DATE].
During an interview on 06/05/26 at 12:30 PM, the Social Worker (SW) Assistant confirmed she was the person responsible for submitting requests for Level II PASRR reevaluations when needed.
The SW Assistant explained it was her understanding that a request for a [NAME] II PASRR reevaluation only needed to be submitted if the significant change in condition directly related to the mental illness.
The SW reported she did not submit a request for a Level II PASRR reevaluation following Resident #9's significant change MDS assessment dated [DATE] because her mental status did not change.
During an interview on 06/05/26 at 3:13 PM, the Administrator stated requests for Level II PASRR reevaluations should be made when a resident had a significant change in condition per the regulatory guidelines.
resident no longer took that medication, and that it was overlooked.
Nurse #1 indicated the medication
Director of Nursing (DON) on 6/5/26 at 10:15 AM revealed that all the nurses were supposed to check
other Administrative Nurses check the medication carts weekly for expired medications.
The DON stated that her expectation was that expired and discontinued medications would be removed from the medication cart and placed in the return to pharmacy bin located inside the medication room.
She further indicated that when a medication was discontinued the Nurse assigned to the cart the day it was discontinued should have removed the medication and placed it into the return to pharmacy bin located inside the medication room.An interview with the DON on 6/5/26 at 10:50 AM revealed that her expectation was that all expired medications would be removed from the medication cart and placed in the return to pharmacy bin located inside the medication room.
She further stated that the breakdown was that Unit Managers and Administrative Nurses were looking through the carts too quickly and the expired medications were being overlooked as a result. An interview with the Administrator on 6/5/26 at 1:25 PM revealed that his expectation was the staff remove expired and discontinued medications from the medication carts and place them in the return to pharmacy bin located inside of the medication room.
345322 06/05/2026
The Laurels of Hendersonville 290 Clear Creek Road Hendersonville, NC 28792
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.