Hensley Nursing & Rehab

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 27, 2022

  On 01/24/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement infection control measures to prevent the spread of COVID, to use appropriate personal protective equipment (PPE), and to keep COVID-positive residents isolated from the non-positive residents in the facility. On 01/24/22 at 12:00 p.m., during the initial tour of the facility, isolation precaution signs were observed to be posted on the doors for eight residents. Containers with PPE supplies were observed at each door. The doors to the isolation rooms were noted to be open to the halls and common areas. Staff was observed entering the isolation rooms and exiting the rooms without donning and doffing PPE. […]

• No harm, potential for more than minimal, patternF640Jan 12, 2023

  Based on record review and interview, the facility failed to electronically transmit resident assessments, within 14 days after completion, for six (#1, 5, 18, 19, 22, and #31) of six residents sampled for resident assessments. The Resident Census and Conditions of Residents, dated 01/10/23, documented 36 residents resided in the facility. Findings: A facility policy, Electronic Transmission of the MDS, revised March 2006, documented in part .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the… […]

• No harm, potential for more than minimal, isolatedF609Aug 13, 2026

  Based on record review and interview, the facility failed to ensure an allegation of sexual abuse was reported to the OSDH within two hours for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. Findings: A facility policy titled Abuse Policy and Procedure, dated 07/23/21, read in part, We will protect our occupants from abuse, neglect, physical abuse, sexual abuse, and misappropriation of resident property. It recognizes resident rights to be free from sexual abuse by staff.All allegations of resident sexual abuse shall be promptly reported to administrator and investigated by facility management. The administrator will report the allegation to the OSDH, APS, and local police. […]

• No harm, potential for more than minimal, isolatedF610Aug 13, 2026

  Based on record review and interview, the facility failed to ensure a thorough investigation was completed for an allegation of sexual abuse for 1 (#1) of 3 sampled residents reviewed for abuse. The administrator identified 26 residents resided in the facility. A facility policy titled Abuse Policy and Procedure, dated 07/23/21, read in part, We will protect our occupants from abuse, neglect, physical abuse, sexual abuse, and misappropriation of resident property. It recognizes resident rights to be free from sexual abuse by staff.All allegations of resident sexual abuse shall be promptly reported to administrator and investigated by facility management. The administrator will report the allegation to the OSDH, APS, and local police. […]

• No harm, potential for more than minimal, isolatedF880May 14, 2025

  Based on observation, record review, and interview, the facility failed to ensure standard infection control precautions were used during urinary catheter care for 1 (#9) of 1 sampled resident for urinary catheters. The DON reported 34 residents resided in the facility and two residents had urinary catheters. Findings: On 05/13/25 at 2:07 p.m., CNA #1 was observed to empty Resident #9's urinary catheter bag. CNA #1 removed the catheter bag from the dignity cover to empty the catheter bag into the urinal. CNA #1 layed the catheter bag on the floor while attempting to drain all the urine from the catheter tubing and bag into the urinal. CNA #1 set the urinal on the floor and placed the catheter bag back into the dignity cover. […]