Hennessey Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Hennessey Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 15, 2024

  On 04/11/24 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident experiencing a significant change in condition and ensure a resident received prescribed antibiotic therapy to treat pneumonia. 03/08/24 Resident #1 had acute change of condition, very weak, unable to stand/sit, 3-4 person assist to transfer, irregular HR, O2 sats 80%, incontinent B&B, and decline in mental status. MD notified. Not sent to ER. 03/19/24 Resident #1's condition deteriorates and they requested to be sent to ER. Returned from ER same day with DX: pneumonia and orders for Augmentin 875mg-125mg tab- 1 tab oral q12hrs x7days. […]

• Actual harm, isolatedF686Apr 15, 2024

  Based on record review and interview, the facility failed to accurately assess residents' risk for and initiate dietary measures to aide in the prevention of avoidable pressure ulcers for one (#1) of two sampled residents reviewed for pressure ulcers. The Administrator identified 31 residents resided in the facility. Findings: Resident #1 had diagnoses that included s/p amputation of left toes and PICC line in upper right arm. Resident #1's Care Plan documents, on 03/15/24, resident was at risk of nutritional decline and had lost 12 lbs. in a month. The RD completed a 'Nutrition Risk Assessment' for Resident #1, dated 03/18/24, with a risk score of NO/LOW RISK, and no interventions for prevention of pressure ulcers were put into place. Discrepancies in the RD assessment included: 1. […]

• No harm, potential for more than minimal, widespreadF577Mar 26, 2026

  Based on observation, record review, and interview, the facility failed to post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives of the residents. The administrator identified 27 residents resided in the facility.Findings: On 03/25/26 at 11:27 a.m., the surveyor walked the halls and the lobby of the facility, there was no posting showing were to find the survey results binder. A Survey Results, Examination of policy, revised 04/2007, read in part, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plan of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such… […]

• No harm, potential for more than minimal, widespreadF727Mar 26, 2026

  Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week.The administrator identified 27 residents resided in the facility. Findings: A Staffing policy, updated 10/2023, read in part, RN must be on duty 8 hours a day 7 days a week. A PBJ Staffing Data Report, dated 10/01/25 through 12/31/25, showed no RN hours on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. An Employee Timecard Report dated 10/01/25 through 12/31/25, did not show the facility had RN hours for 8 consecutive hours on the following dates, 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. […]

• No harm, potential for more than minimal, widespreadF801Mar 26, 2026

  Based on record review and interview, the facility failed to ensure the food service supervisor completed certification as a certified dietary manager within three years of beginning employment per State requirement.The administrator identified 27 residents who received meals from the kitchen. Findings:The Food and Nutrition Services Staff policy, revised 10/20, read in part, Nutrition service manager if not already certified will be enrolled in an accredited/approved program within regulatory timeframe.An undated Employee Information Report, showed the dietary supervisor was hired on 02/04/20.There was no documentation the dietary supervisor had completed a certified program.On 03/23/26 at 1:47 p.m., the dietary supervisor stated they have not completed a certification course. […]