Durham-Hensley Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Durham-Hensley Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF628Jun 10, 2026

  Based on medical record review and interviews, the facility failed to notify the Long-Term Care (LTC) District State Ombudsman of resident discharges and transfers from the facility for 4 residents (Resident #7, Resident #1, Resident #37, and Resident #90) of 4 residents reviewed for discharges and transfers. The findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Sepsis, Diabetes Mellitus, and Urinary Tract Infection. […]

• No harm, potential for more than minimal, isolatedF759Jun 10, 2026

  Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain a medication error rate less than 5 percent when medications were omitted and not administered timely for 1 resident (Resident #10) of 5 residents observed for medication administration, resulting in 4 medication errors out of 42 medication administration opportunities, an error rate of 9.52%.The findings include:Review of the facility's policy titled, Medication Administration-Unit Dose Cart System, reviewed on 1/2026, revealed .correctly administer medications as prescribed .Utilize the 6 rights of medication administration .Verify right ordered time for administration .Review of the facility's policy titled, Medication Administration: Errors/Drug Reactions, reviewed… […]

• No harm, potential for more than minimal, isolatedF919Jun 10, 2026

  Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was in reach for 1 resident (Resident #50) of 63 residents observed.The findings include:Review of the facility's policy titled, Call System, dated 7/2025, revealed .the call light should be easily accessible to the Resident at all times .Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Dementia, Left Femur Fracture, and Syncope.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was dependent on staff for ADL's [Activities… […]

• No harm, potential for more than minimal, isolatedF645Aug 23, 2023

  Based on record review and interview the facility failed to resubmit a timely Level l (one) Pre-admission Screening and Resident Review (PASRR) for 1 resident (#40) of 6 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-Admission Screening & Resident Review (PASRR), dated ,d+[DATE], showed .Level l's are submitted- For everyone regardless of pay source admitting to a Medicaid certified Nursing Facility .Expiration of a time-related stay .Submit a new level l no less than 10 days before expiration date . Resident #40 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, General Anxiety Disorder, and Post-Traumatic Stress Disorder. […]

• No harm, potential for more than minimal, isolatedF656Aug 23, 2023

  Based on facility policy review, record review, observation and interview, the facility failed to develop a comprehensive care plan to meet the trauma informed care needs of 1 resident (Resident #9) of 29 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Trauma Informed Care, dated 7/2023, showed .Trauma survivors must receive .trauma-informed care .the interdisciplinary team .will develop a care plan to identify triggers and interventions to minimize .effect of the trigger for the resident . Resident #9 was admitted to the facility on [DATE] with diagnoses including Transient Cerebral Ischemic Attacks and Post Traumatic Stress Disorder (PTSD). […]