Henderson Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders for 1 of 3 (Resident #13) sampled residents reviewed for Urinary Tract Infection. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician.verify dose.administer medication as ordered.Sign Mar [Medication Administration Record] after administered [medications]. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Uropathy, Benign Prostatic Hyperplasia, and Chronic Kidney Disease. Review of the Physician's Order dated 7/31/2025, revealed .Gentamicin Sulfate Solution [an antibiotic used to treat an infection] Inject 80 mg [milligrams] intramuscularly [IM] one time a day for UTI [Urinary Tract Infection] for 3 Days. Review of the Medication Administration Record for July 2025, revealed Gentamicin Sulfate…

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 facility policy review, medical record review, observation, and interview, the facility failed to accurately assess nutritional status of residents, failed to follow the facility's policy for monitoring weights and failed to have a nutritional intervention provided timely for 2 of 4 (Resident #8 and #9) residents reviewed for nutrition. The findings include: 1. Review of the facility's policy titled, Weight System, revised 7/9/2025, revealed .Weekly weights are completed for.Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 months or 10% in 6 months.All weight changes are considered unplanned unless the MD [medical doctor] has documented a plan for desired weight change and the facility has care planned PRIOR to the weight change occurring.DON [Director of Nursing] or designee.will review monthly and weekly weights.Request reweights on a resident's weekly weight if a change greater than 2% change and on a resident's monthly weight if greater than 5%, 7.5% or 10% change is…

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 policy review, medical record review, observation, and interview, the facility failed to follow physician's orders, provide care and services regarding oxygen therapy, and failed to assess residents for the use of oxygen for 2 of 3 (Resident #42 and #75) sampled residents reviewed for respiratory care.The findings include: 1. Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Staff shall document the initial and ongoing assessments. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician.verify dose.administer medication as ordered.Sign Mar [Medication Administration Record] after administered [medications]. 2. Review of the medical record revealed Resident #42 was admitted to the facility…

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 policy review, manufacturer's guidelines review, maintenance history report review, observations, and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to label and date food stored in the cooler and dry storage, and failed to ensure food stored for resident consumption was not expired. The facility had a census of 92 residents with 91 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's undated policy titled, Sanitation Inspection, revealed, .policy of this facility . conduct inspections to ensure food service areas are clean, sanitary and in compliance .All food service areas shall be kept clean, sanitary .inspections to be conducted .Dry storage .Freezer .Refrigerator .Food preparation area .General dietary observations . The facility was unable to provide a dietary policy for food storage. 2. Review of the manufacturer's guidelines for the facility's ice machine dated 2018, revealed, .Cleaning/Sanitizing Procedure .This procedure must be…

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 policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 7 of 15 staff members (Certified Nursing Assistants (CNA) I,K,M,N,S, Licensed Practical Nurse (LPN) H, and Registered Nurse (RN) E) failed to knock and/or announce self when entering resident rooms and failed to use courtesy titles when addressing residents during dining. The findings include: 1. Review of the undated facility's policy titled, Courtesy Titles Policy, revealed .employees should be constantly cautious to avoid using first names when addressing residents regardless of how familiar they may become .Always use Mr. and Mrs. and do not use first names or nicknames .exceptions made .if the resident makes a special request .shall be documented in the medical record . 2. Observation during dining on 7/29/2024 at 11:58 AM, revealed CNA I placed the tray on Resident #71's bedside table and said, .Here darling . Observation during dining on 7/29/2024 at 12:00 PM, revealed CNA S placed the tray on Resident #53's over bed table and said,…

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 policy review, medical record review, observation, and interview, the facility failed to provide appropriate respiratory care and services consistent with professional standards of practice for 2 of 2 nurses (Registered Nurse (RN) F and Licensed Practical Nurse (LPN) C) observed for tracheostomy care, and failed to obtain a physician's order for 1 of 3 (Resident #36) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility's policy titled, TRACHEOSTOMY CARE, dated 10/21/2022, revealed The facility will ensure that residents who need respiratory care, including tracheostomy [a surgically created opening into the trachea that allows the person to breathe through a tube inserted into the opening] care .is provided such care consistent with professional standards of practice .The facility will provide necessary respiratory care and services, such as oxygen therapy . tracheostomy care .Tracheostomy care will be provided according to physicians orders .Maintain .an Ambu…

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 facility policy review, medical record review, observation and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 3 of 6 Medication (Med) Storage Areas (501-506 Hall Cart, 507-514 Hall Cart, and 400 Hall Cart) and for 8 of 8 (Resident #14, #28, #30, #39, #67, #227, #277 and #376) random medication observations. The findings include: 1. Review of the facility's undated policy titled, Controlled Substance Accountability, revealed It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record .…

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 policy review, medical record review, observation, and interview, the facility failed to ensure 3 of 4 (Licensed Practical Nurse (LPN) B, C, and Registered Nurse (RN) E) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 10 errors were observed out of 29 opportunities, resulting in a medication error rate of 34.48%. The findings include: 1. Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in manner to prevent contamination or infection .Administer medication as ordered .Wash hands using facility protocol and product .If medication is a controlled substance, sign narcotic book . Review of the facility's undated policy titled, Medication Administration via Enteral Tube, revealed It is the policy of this facility to ensure the safe and effective administration of medications via enteral…

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 policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 15 staff members (Certified Nursing Assistant (CNA) L, N, and O) observed during dining failed to perform hand hygiene, and when 1 of 6 staff members (Licensed Practical Nurse (LPN) C) failed to observe Enhanced Barrier Precautions for 1 of 6 (Resident #326) sampled residents and 2 of 4 (LPN B and C) nurses failed to clean reusable equipment during medication administration. The findings include: 1. Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .This applies to all staff working in all locations within the facility .Conditions [for performing hand hygiene] .Between resident contacts .After handling contaminated objects . Review of the facility's undated policy titled, Cleaning and Disinfection of…

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 policy review, observation, and interview the facility failed to ensure that medications were properly and securely stored when 2 of 4 nurses (Licensed Practical Nurse (LPN) B and C) left medications unattended and unsecured on the 400 Hall and 600 Hall Medication Carts. The findings include: 1. Review of the undated facility policy titled, Medication Storage revealed .All drugs and biologicals will be stored in locked compartments (i.e. [that is], medication carts .During medication pass, medications must be under the direct observation of the person administering medications or locked in the medications storage area/cart . 2. Observation outside of Resident #327's room on 7/30/2024 at 12:33 PM, revealed LPN C left the medication cup with crushed Baclofen (treatment of muscle pain) on the 600 Hall Medication Cart unattended and unsecured while donning Personal Protective Equipment (PPE). Observation in Resident #327's room on 7/30/2024 at 12:42 PM, revealed LPN C went to wash hands in the bathroom while the medications were on the overbed tray outside the bathroom at the…

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 policy review, observation, and interview, the facility failed to ensure food was stored properly when there were unlabeled, undated, and expired items in 2 of 2 resident nourishment refrigerators. The findings include: 1. The facility's undated policy titled, Use or storage of food brought in by family or visitors, revealed .All food items .by the family or visitor brought in must be labeled . and dated .The facility may refrigerate labeled and dated .items in the nourishment refrigerator .If not consumed within 3 days, food will be thrown away by the facility staff . 2. Observation in the 500/600 Hall Nutrition Room on 7/29/2024 at 3:46 PM, with Licensed Practical Nurse (LPN) G revealed the following in the residents' nourishment refrigerator: A cup of (named brand) ice cream unlabeled and undated. Three (3) tubs of (named brand) ice cream unlabeled and undated. A gallon of orange juice unlabeled and undated. 3. Observation in the 300/400 Nutrition Room on 7/30/2024 at 3:59 PM, with LPN H, revealed the following in the residents' nourishment refrigerator: A box of…

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 facility document review, medical record review, observation, and interview, the facility failed to maintain an effective pest control program in 6 of 70 (Resident #2, #3, #5, #6, #9, and #15) resident reviewed for flies in their rooms, the failure to prevent parasites or possible maggots for 1 of 70 (Resident #5) resident reviewed for maggots in the wound, and 3 of 4 (300-Hall, 400-Hall and 500-Hall) halls on 4 of 8 ( 10/24/2023, 10/25/2023, 10/30,2923 and 11/1/2023) days of onsite observations. The findings include: 1. Review of the Named Pest Control Contract dated 1/1/2023, revealed . [Name Pest Control Company] proposes to provide structural pest management services for the control of cockroaches, ants, rodents, silverfish and other structural pest infestations (with the exception of flies, fleas, bed bugs, mosquitoes and wood destroying organisms) by periodic treatment using products according to approved label procedures . 2. Review of medical record, revealed Resident #2 was admitted to the…

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 policy review, medical record review, observation, and interview, the facility failed to ensure that an indwelling urinary catheter was secured for 1 of 3 sampled residents (Resident #6) reviewed for indwelling urinary catheter. The findings include: 1. Review of the facility's undated policy titled, Indwelling Catheter Use and Removal, revealed .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter . 2. Review of medical record, revealed Resident #6 was admitted on [DATE] with a readmission on [DATE] with diagnoses of Dysphagia, Alzheimer's, Heart Failure, Defibrillator, Neuromuscular Dysfunction of Bladder and Gastrostomy. Review of the Physician's Orders dated 6/12/2023, revealed Resident #6 had an indwelling urinary catheter (small tube that is inserted into the bladder to drain urine). Observation in the resident…

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.