Henderson Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Mar 3, 2023

  Based 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. […]

• Immediate jeopardy, patternF580Mar 3, 2023

  Based 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 01/24/2023. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. […]

• Immediate jeopardy, patternF684Mar 3, 2023

  Based 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 01/24/2023. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. […]

• Actual harm, isolatedF600Sep 17, 2025

  Based 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.Findings included:1.Review of an admission Record for Resident #1 dated 9/16/2025 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), peripheral vascular disease (poor… […]

• No harm, potential for more than minimal, widespreadF887May 14, 2025

  Based 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,… […]