A list of the most recent deficiencies for Henderson Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-17 | 2023-10-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-17 | 2023-10-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-10-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-17 | 2023-10-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-10-05 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-17 | 2023-10-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-17 | 2023-10-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-17 | 2023-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-10-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-17 | 2023-10-05 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-17 | 2023-10-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-17 | 2023-10-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-17 | 2023-10-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-11 | 2023-03-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-07 | 2022-11-15 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-10-07 | 2022-11-15 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-07 | 2022-11-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-07 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-03 | 2022-06-23 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Develop a communication plan. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-29 | 2022-06-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-03 | 2022-06-02 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-05-03 | 2022-06-02 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-29 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-03 | 2022-05-27 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-05-03 | 2022-05-27 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-05-03 | 2022-05-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-03 | 2022-05-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-03 | 2022-05-26 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-05-03 | 2022-05-26 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-05-03 | 2022-05-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-03 | 2022-05-26 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-05-03 | 2022-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-03 | 2022-05-25 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-29 | 2022-05-24 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-05-03 | 2022-05-19 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-29 | 2022-05-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-17 | 2021-11-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-02 | 2021-11-29 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-02 | 2021-11-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-02 | 2021-11-29 | Y |
| Have policies on smoking. | Health | 2021-11-02 | 2021-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-16 | 2021-05-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-05-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-16 | 2021-05-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-16 | 2021-05-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-16 | 2021-05-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-16 | 2021-05-28 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-06-27 | 2019-09-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-28 | 2019-08-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-28 | 2019-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide appropriate foot care. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-28 | 2019-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-28 | 2019-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-28 | 2019-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | Not Fixed | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-13 | Not Fixed | Y |
