Henderson Health and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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%.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a resident environment that was safe, clean and sanitary to prevent the spread of disease-causing organisms and infections when Resident #5 who had wounds infected with maggots, was observed handling linens and propelling throughout the facility with the drainage/maggots leaking onto the floor from his wheelchair and when 3 of 70 sample residents (Resident #12, #13 and #14) reviewed for infection control. The facility had a census of 70. A partial extended survey was conducted 11/1/2023 through 11/2/2023. [...]

Inspectors wroteBased on policy review, timeanddate.com, medical record review, fall investigation review, observation and interview, the facility failed to provide adequate supervision for a cognitively impaired resident at risk of elopement, and ensure a safe environment for 2 of 7 (Resident #16 and #11) sampled residents reviewed for accidents, and supervision. On 10/31/2023 Resident # 16 exited the facility through the front exit door, by a visitor who entered the door code, opened the door, and let Resident #16 outside into the courtyard, an unsafe environment. Resident #16 was observed knocking on the 300/400 Hall exit door approximately 174.1 feet from the front door. The temperature outside was 46 degrees. The facility failed to conduct appropriate elopement assessments and elopement drills on all shifts with the elopement on 10/31/2023. [...]

Inspectors wroteBased on policy review, Job Description, record review, observation, and interview, the facility failed to maintain an infection prevention program to prevent the development and transmission of infection when Resident #5, whose wounds were infected, with maggots, and draining, was observed propelling in his wheel chair and draining onto the facility floor and when Resident #5 was observed to be scratching and touching his wounds with his hands, and then touching towels/linens on the clean linen cart. The facility failed to ensure staff used appropriate infection control practice for 3 of 3 (Certified Nursing Assistant (CNA) #1, #2 and #3) CNAs observed to perform personal hygiene care. The facility had a census of 70. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.