Henderson Health And Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF584Dec 4, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 4, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF880Dec 4, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF600Apr 21, 2022

  Based on policy review, weather website statistics review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent neglect for 1 of 11 sampled residents (Resident #1) reviewed for wandering/elopement behavior. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The temperature was approximately 64 degrees. The staff were unaware the resident was missing from the facility and the resident was outside the facility, unsupervised for approximately 20 minutes. […]

• Immediate jeopardy, isolatedF610Apr 21, 2022

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 11 sampled residents (Resident #1) reviewed for wandering/elopement behaviors. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy (IJ) when Resident #1, a vulnerable resident, exited the facility and was found approximately 237 feet from the alarming exit door, seated in a wrought iron chair in the rocks. The staff were unaware the resident was missing from the facility and the resident was outside the facility, unsupervised for approximately 20 minutes. […]