Henson Park Health & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 21, 2023

  Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. […]

• Immediate jeopardy, isolatedF607Oct 21, 2023

  Based on interviews, record review, review of the facility's investigative report, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken to protect the residents from abuse for one (1) of three (3) sampled residents (Resident #9). Review of the facility's Initial Report, dated 10/12/2023, revealed Certified Nursing Assistant (CNA) #33 was working in a resident's room when she heard a scream and stepped into the hallway. […]

• Immediate jeopardy, isolatedF835Oct 21, 2023

  Based on interview, record review, review of the facility's policies, review of the facility's investigative report, and review of the Administrator's and Director's of Nursing job descriptions, it was determined the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility also failed to protect residents from abuse; failed to develop and implement policies that prohibited and prevented abuse; and, failed to establish coordination with the Quality Assurance Performance Improvement (QAPI) program related to abuse allegations. […]

• Immediate jeopardy, isolatedF578Sep 29, 2023

  Based on review of the Resident's Advanced Directives, it was determined the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment, and to formulate an advanced directive for one (1) of twenty-five (25) sampled residents (Resident #10). Review of the resident's Advanced Directives revealed the resident had an Advanced Directive for Full Code on [DATE]. However, there was no evidence the Advanced Directive was updated to ensure accuracy. Review of Resident #10's Admission Record revealed the facility admitted the resident on [DATE] with an Advanced Directive designated as Full Code. Further review revealed the resident's code status had changed on [DATE] to Do Not Resuscitate (DNR). […]

• Immediate jeopardy, isolatedF600Sep 29, 2023

  Based on interview, record review, review of the facility's investigative report, and review of the facility's abuse policy, it was determined the facility failed to protect one (1) of three (3) sampled residents from abuse/neglect (Resident #9). During an interview with Certified Nursing Assistant (CNA) #33, she stated CNA #35 pushed Resident #9 back into the bed on 10/12/2023 while yelling at the resident and saying, I'm not dealing with your ass tonight. CNA #33 further stated she left the resident's room to report the incident to Licensed Practical Nurse (LPN) #13 who informed her to call the Director of Nursing (DON). She stated CNA #35 was left alone with Resident #9 while she went to inform the nurse. […]