Henderson Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 3, 2022

  Based on observation, interview and document review, the facility failed to ensure hot water temperatures were within safe ranges in resident rooms and a shower room which created a potential for harm to residents and to ensure fall preventive measures was followed for 2 of 40 sampled residents (Residents 195 and 41). Findings include: On 04/26/2022 at 9:05 AM, hot water temperatures obtained at bathroom sinks in resident rooms in A building on the 500-hall revealed the following: Room 501 was 167.0 degrees Fahrenheit Room 502 was 166.0 degrees Fahrenheit Room 503 was 160.4 degrees Fahrenheit Room 504 was 166.0 degrees Fahrenheit Room 505 was 161.2 degrees Fahrenheit Room 506 was 154.3 degrees Fahrenheit Room 507 was 160.4 degrees Fahrenheit Room 508 was 160.5 degrees Fahrenheit Room 509… […]

• Actual harm, isolatedF689Dec 13, 2023

  Based on observation, interview, record review, and document review, the facility failed to secure a resident in a wheelchair when it did not ensure the pre-transport securement checklist was completed, and the shoulder strap was placed prior to transit for 1 of 20 sampled residents (Resident 1). This deficient practice led to a fall incident inside the facility bus, resulting in fractures (broken bones) of the third, fourth, and fifth metacarpal bones of the dominant right hand. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including dependence on dialysis and absence of left and right below knees. […]

• No harm, potential for more than minimal, widespreadF814May 3, 2022

  Based on observation, interview, and document review, the facility failed to maintain the garbage storage area in a manner to prevent the harborage and feeding of pests for four of four garbage dumpsters. Findings include: On 04/26/2022 at 8:30 AM, three garbage dumpsters in the southeast parking lot were overfilled with garbage bags and other materials. The lids of the dumpsters were open to the air. Used gloves, isolation gowns, bags containing disposed materials, used briefs, and papers were observed around the dumpster and all over the parking lot area, including the back fence shared with two residential facilities and the street out of the facility's boundaries. Dark sticky fluids were observed under and around the dumpsters. […]

• No harm, potential for more than minimal, patternF837Jan 16, 2026

  Based on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors and for 6 of 28 residents (Residents 4, 9, 11, 15, 18, and 19). This deficient practice had the potential to lead to inappropriate tiering and state payments for residents in a Medicaid Behaviorally Complex Care Program.Findings include:F0837: Governing BodyBased on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors and for 6 of 28 residents (Residents 4, 9, 11, 15, 18, and 19). […]

• No harm, potential for more than minimal, patternF880Aug 1, 2025

  Based on observation, interview, record review, and document review, the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted and staff wore appropriate personal protective equipment (PPE) when providing direct care to residents with indwelling medical devices for 4 of 35 sampled residents (Residents 132, 196, 89 and 194). These deficient practices had the potential to place residents, staff, and visitors at risk for cross-contamination and transmission of multidrug-resistant organisms (MDROs), compromising the infection prevention and control program.Findings include:1) Resident 132 (R132) R132 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), gastrostomy, and colostomy. […]