Henderson Nursing and Rehabilitation Center

Based on observation, interview, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 sampled residents, Resident (R)79. The findings include: Review of the facility's policy titled, Medication Administration, revised 03/2026, revealed the purpose is for medications to be administered by licensed staff who will follow the established facility infection control procedures. Review of the facility's policy titled, Hand Hygiene Protocol, not dated, revealed hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Gloves may be used including but not limited to food and medication preparation areas. In addition, gloves changed, and hand hygiene performed before moving from a contaminated-body site to a clean-body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement a comprehensive person centered care plan for 2 of 23 sampled residents, (Resident (R)50, and R42). 1. Review of R50's comprehensive person centered care plan revealed the resident was to wear left and right hand and knee splints daily for six days. However, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM , on 05/15/2025 at 9:20 AM and 11:30 AM of R50, revealed two hand splints lying on the resident's bedside table; and observation on 05/16/2025 at 10:18 AM revealed the hand splints were located in R50's closet. Additionally, observation on 05/13/2025 at 12:03 PM and 2:18 PM, on 05/14/2025 at 9:10 AM, 11:23 AM revealed R50 lying on her bed with no knee splints in place and her knees drawn up to her chest. 2. Review of R42's comprehensive person centered care plan revealed the resident was not to have chips and was to be supervised with all (oral) intake. However, observation on 05/13/2025 at 11:42 AM and 2:48 PM, revealed R42…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion (ROM) for 1 of 23 sampled residents, (Resident (R)50). R50 was care planned with interventions to have left and right wrist and knee splints daily for six days. However, observation revealed two hand splints lying on R50's bedside table or located in the resident's closet. Additionally, observation revealed R50 did not have knee splints on while in bed and the resident's knees were drawn up to her chest. The findings include: Review of the facility policy, Restorative Nursing Standards of Practice, revised 12/2023, revealed the facility strived to promote a restorative nursing program that encourages all residents to attain or maintain their highest practical level of function. Per review, residents were to be evaluated for potential nursing restorative nursing needs on admission, quarterly, and with a change in condition. Continued review revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, the facility failed to ensure residents received and consumed foods in the appropriate form or the appropriate nutritive content as prescribed for 1 of 23 sampled residents, (Resident (R)42). R42 had a diet order for supervision with all (oral) intake and to have no chips. However, observation on 05/13/2025 at 11:42 AM and 2:48 PM, revealed R42 self-propelling throughout the facility while eating a bag of potato chips unsupervised. The findings include: A policy was requested however, the Administrator stated the facility did not have a policy related to the deficient practice. Record review revealed the facility admitted R42 on 03/13/2020, with diagnoses that included Dysphagia, Idiopathic Epilepsy, and Profound Intellectual Disabilities. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/11/2025 for R42, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero out of 15, indicating the resident was rarely or never understood.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents sampled for wound care out of the total sample of 23 residents (Resident (R)21). Staff providing R21's wound care failed to utilize proper hand washing during the resident's wound care procedure. The findings include: Review of the facility policy, Hand Hygiene, undated, revealed hand hygiene meant cleaning your hands by using either handwashing (washing hands with soap and water) or using hand sanitizer. Per review, hand hygiene was to be performed; before and after glove use; and before and after having contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressing. Review further revealed gloves were to be changed and hand hygiene performed before moving from a contaminated body site to a clean body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all residents' drugs and biologicals which were expired were removed from all medication administration areas in order to prevent possible administration to residents. The findings include: Review of the facility policy titled, Administering Oral Medications Level III Purpose, undated, revealed, staff were to check the expiration dates on all residents' medications and return any expired medications to the Pharmacy. Observation 04/29/2021 at 10:10 AM, of the refrigerator located in the facility's Medication Prep Room, revealed one (1) bottle of Omeprazole Suspension 20 milligrams/milliliter (mg/ML) with an expiration date of 03/21/2021. Observation on 4/30/2021 at 9:18 AM of the Hall 1 medication carts #1, #2 and #3 and the Hall 2 medication carts #1, #2 and #3 revealed the following expired medications: *Ondansetron 4 mg tablets (tabs), 4 tabs with an expiration date of 02/15/2021 *Loperamide 2 mg, 13 tabs - with an expiration date of 02/08/2021 *Ibuprofen 800 mg, 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety as related to the kitchen floor not being clean. Review of facility policy titled, Environment, revision date of 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. Observation on 04/27/2021 at 9:51 AM, while on initial tour of the kitchen with the Dietician, it was noted the floors were dirty with dirt, debris and dirty paper towels noted in the floor. Interview with the District Manager of Dietary, on 04/30/2021 at 8:13 AM, revealed that the dietary staff are expected to keep the floor clean. States that they usually clean the floor between breakfast and lunch. He would expect the floor to be free from debris and dust.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of twenty-four (24) sampled residents (Resident #3). The facility failed to ensure Resident #3's Comprehensive Care Plan was revised to include the intervention for bladder cycling related to the Physician's Order received on 04/08/2021. The resident's care plan was not revised to include the intervention until 04/26/2021, fourteen (14) days after the order was received. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual dated 10/2018, revealed residents' care plans were to be reviewed and revised based on the resident's needs, changing goals, preferences and in response to current interventions. Record review revealed the facility admitted Resident #3 on 10/18/2020, with diagnoses which included: Obstructive and Reflux Uropathy; Sepsis; Metabolic Encephalopathy; Acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review, it was determined the facility failed to ensure residents received the necessary care and services to promote healing and prevent infection for one (1) of twenty-four (24) sampled residents, Resident (#33). Observation of a dressing change for Resident #33 revealed the nurse failed to ensure reusable resident care equipment was cleaned and sanitized before and after each use. The findings include: Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 10/2018 revealed resident care equipment which included reusable items and durable medical equipment were to be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Continued review revealed reusable items, such as stethoscopes and durable medical equipment, etc. were to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, it was determined the facility failed to ensure all residents requiring a therapeutic diet prescribed by the Physician received the diet as ordered for one (1) of twenty-four (24) sampled residents (Resident #56). Resident #56 had a Physician ordered dietary change for a therapeutic diet which the facility failed to implement immediately. The findings include: Review of the facility policy entitled, Therapeutic Diets, revision date of 09/2017, revealed all residents were to have a Physician ordered diet which included regular, therapeutic and modified texture diets. Continued review revealed the licensed nurse accepting the diet order from the prescriber was to complete and sign the facility's Diet Requisition Form. Further review revealed the licensed nurse was to ensure the Diet Requisition Form included the diet ordered by the prescriber, any food allergies and specific food preference requests. In addition, review revealed all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.