Henderson Health & Rehabilitation Center

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 8/17/25 at approximately 4:00 p.m. when Resident #2 pushed her down and kicked her causing two skin tears and pain rated as a 10/10 on a numeric pain scale following the incident. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life.

Inspectors wroteBased on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid -19(a severe acute respiratory syndrome ) immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 74 of 74 residents living in the facility and 5 of 5 residents who were reviewed for immunizations (Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57) The facility failed to document, in Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 1 smoking area reviewed for smoking safety. The facility failed to ensure cigarette butts were not discarded into a regular trash can that also contained paper trash on 5/12/25 causing a fire hazard. The facility failed to ensure regular trash was not discarded into the red metal ashtray container on 5/12/25 causing a fire hazard. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 4 residents (Resident #12) reviewed for accuracy of assessments. The facility failed to accurately code the 04/30/25 MDS for an in-dwelling catheter (tube inserted into the bladder to drain urine) used for Resident #12. This failure could put residents at risk for lack of proper care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 12 residents (Resident #23) reviewed for ADL care. The facility failed to ensure Resident #23 had a shower and shave from 4/15/2025 to 5/08/2025. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #39) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service on 5/12/25. This deficient practice place residents at risk of injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, 1 of 4 medication carts (hall two cart) reviewed for storage of medications. The facility failed to ensure LVN C kept the hall two medication cart secured and was unable to be accessed by unauthorized personnel or residents on 05/12/25. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.

Inspectors wroteBased on observations, interviews, and record reviews, 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 8 residents (Resident #57) and 2 of 8 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #57 on 5/12/2025. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that: 1. Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges. 2. Resident #2's bed sheets and pillowcase had scattered brown stains on them. This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 (Resident #1) reviewed for dignity in that: CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed. This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth. Findings Include: Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems). [...]

Inspectors wroteBased on observation, interview, and record review, 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 2 of 4 residents (Residents # 20 and #52) reviewed for infection control practices. 1. LVN T failed to change her gloves after performing foley care on Resident #20 and touched clean surfaces. 2. CNA K failed to wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #52. 3. CNA J and CNA K failed to wash or sanitize their hands after performing foley catheter care for Resident #52. These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 18 residents (Resident # 28 and Resident # 42) reviewed for resident rights. 1. The facility failed to ensure Resident #28's dignity when dining while the Nurse Practitioner assessed the resident's foot callous at the dining room table while the resident was eating with other residents eating . 2. The facility failed to ensure Resident #42 had toilet paper, paper towels and soap in dispenser for personal hygiene use. These failures could place residents at risk for a decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 6 (Resident #33) residents reviewed for environment. 1. The facility failed to ensure Resident #33's bathroom sink was free of brown substances. 2. The facility failed to ensure soiled briefs were removed from Resident #33's trash can. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission and included the minimum healthcare information necessary to properly care for a resident for 2 of 7 residents (Resident #181 and Resident #182) reviewed for care plans. The facility failed to develop and implement a baseline care plan within 48 hours of admission for Residents #181 and #182. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #20) reviewed for care plans. The facility failed to revise Resident #20's care plan to reflect his choice to be a DNR. This failure could place residents at risk for not receiving appropriate care and interventions to meet their current choices and needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Residents #39 and #9) reviewed for accident hazards. 1. The facility failed to ensure Resident #39's shoulder seat belt was buckled prior to transport. Resident #39 slid out of the wheelchair to the floor when the facility transportation van stopped at a stop sign. 2. The facility failed to ensure CNA H and LVN I transferred Resident #9 safely when they tilted Resident #9's wheelchair back onto the anti-tip bars with all 4 wheelchair wheels not touching the floor and lowered Resident #9 into the wheelchair via mechanical lift. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (Medication cart on hall 1 and medication cart hall 2) reviewed for pharmacy services. The facility failed to lock the medication carts for hall 1 and hall 2. This failure could place residents at risk of not having their medications available as prescribed, a drug diversion, and an adverse reaction if accessed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 4 of 6 residents reviewed for communicable disease (Resident #'s 41, 45, 54, and 74) and 1 of 12 months reviewed for infection control tracking and trending (January 2023). The facility failed to initiate transmission-based precautions with the onset of the diagnosis of shingles F(painful rash with blisters) for Resident #45. The facility failed to initiate transmission-based precautions with the onset of and ongoing of diarrhea for Resident #74. CNA C failed to change gloves and washing her hands during incontinent care and prior to exiting Resident #74's room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 6 residents reviewed for notification of changes. (Resident #'s 45 and 74) The facility failed to notify the resident's physician when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. The facility failed to notify the resident's physician when Resident #74 had diarrhea since admission on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 6 residents reviewed changes of condition. (Resident #'s 41, 45 and 74) The facility failed to obtain a PCR HSV and VZV lab when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. The facility failed to obtain a stool culture when Resident #74 had on-going diarrhea since admission on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled for 1 of 22 residents (Resident #59) and 1 of 5 medications carts. (Station #2 medication aide cart). The facility failed to remove expired prostat liquid (concentrated liquid protein), expired melatonin, and 3 bottles of expired eye drops from station #2's medication aide cart. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. The facility failed to ensure the security of Resident #59's Haldol medication upon delivery of medications on 02/06/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 3 (Resident #131) reviewed for admission physician orders. The facility failed to ensure Resident #131 had a physician's order for the use of oxygen. This failure could place residents at risk of not receiving appropriate care, treatment services, and at risk for low oxygen and/or high oxygen levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 7 resident (Resident #131) reviewed for PASRR Level I screenings. The facility failed to ensure the accruecy of the PASRR Level 1 screening for Resident #131. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 4 residents reviewed for baseline care plans. (Resident # 131) The facility failed to address Resident #131's communication, daily preferences, ADLs, devices, health conditions, medical conditions, safety risks/falls, skin, smoking, dietary, and therapy on the computerized base-line care plan. This deficient practice could place residents at risk for missed care.

Inspectors wroteBased on interview, and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 of 1 (Resident #45) reviewed for comprehensive person-centered care plans. The facility failed to revise Resident #45's care plan when he was receiving treatment for shingles (painful rash with blisters). This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 3 of 4 residents (Residents #280, #74 and #131) reviewed for ADL care. The facility failed to ensure Resident #280 was routinely showered/bathed. The facility failed to ensure Resident #131 was routinely showered/bathed. The facility failed to ensure Resident #74's brief with bowel incontience was changed prior to her morning meal. These failures could place residents at risk of not receiving care/services, decreased quality of life impacting their loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 6 residents reviewed for accidents hazards. (Resident #130) The facility failed to implement a fall intervention when Resident #130 said he fell on [DATE] to prevent Resident #130 from falling on 02/27/2023. These failures could place residents at risk for falls and falls with serious injury.

Inspectors wroteBased interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when there was a nutrition a problem for 2 of 6 residents reviewed for unplanned weight loss. (Resident #'s 74 and 130) The facility failed to ensure a weight variance was addressed and documented to ensure management of weight loss for Resident #'s 74 and 130. These failures could place residents at risk for undetectable weight loss, malnutrition, and poor quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Station #2's nurse's cart) The facility failed to ensure Resident #27's Basaglar (long-acting insulin to control high blood sugar) insulin pen was dated when opened on station #2's nurse's cart. This failure could place residents at risk for not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 22 residents reviewed for laboratory services (Residents #20 and 77). The facility failed to obtain ordered CBC (Complete Blood Count), CMP (Complete Metabolic Panel, and Mg (Magnesium) levels for Resident #20. The facility failed to obtain ordered CBC, CMP and Mg levels for Resident #77. These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.