Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Henderson Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced medication administration and documentation errors when an LPN documented PRN Oxycodone as given without removing it from the narcotic supply or actually administering it, and another LPN signed off a MAR as if routine medications were administered before taking them to a resident’s bedside. Family members questioned the accuracy of the pain medication administration, and review of the MAR and narcotic records showed discrepancies. Facility leadership and clinical staff confirmed that medications were expected to be administered first and then documented, and that such discrepancies met the facility’s definition of a medication error requiring reporting and review under its medication error and administration policies.
The governing body failed to oversee a contracted vendor that completed behavior documentation used for Medicaid Behaviorally Complex Care Program (BCCP) applications. Behavior Frequency Documentation Data Sheets for several residents with complex medical and psychiatric conditions contained daily behavior entries and numerous initials that could not be linked to facility staff, including repeated use of the initials "AB." The vendor’s staff documented multiple behavioral interventions—such as token economies, loss of privileges, PBIS-style strategies, classroom-type rewards, time-outs, and even corporal punishment—as effective or otherwise, despite these interventions not appearing in resident care plans and not being used by facility staff. The DON confirmed facility staff did not have access to or complete these sheets, while contracted agency leadership stated they used this documentation to prepare and submit BCCP applications without confirmed facility review.
The facility failed to post EBP signage and ensure staff wore required PPE when providing direct care to residents with indwelling medical devices, including PEG and G-tubes. Staff were observed giving care without gowns, and multiple LPNs, RNs, and CNAs stated they were unaware that gowns were required for tube feeding or other high-contact care. The IP confirmed the facility had not fully implemented EBP and that training for nursing staff had not been provided.
Broken blinds, damaged dressers, and uncovered coaxial cable openings were observed in several resident rooms, leaving the rooms not presented as a homelike environment. The Maintenance Director and ADON were unaware of the issues, and the ADON stated the items should be continually maintained like a homelike environment. The facility’s Resident Rights Policy states residents have a right to a safe, clean, comfortable, and homelike environment.
Failure to Notify Mental Health Authority After Psychiatric Change: The facility did not ensure a PASARR level 2 referral was completed after a resident with a history of schizoaffective disorder, bipolar disorder, major depressive disorder, OCD, and anxiety had a significant mental health change and became homicidal, requiring a legal hold and ED transfer. Record review showed the resident’s psychiatric change of condition met criteria for PASARR review, but the chart lacked documentation that the referral was made.
A resident with contractures and limited hand dexterity was documented as a smoker, but no smoking safety assessment or physician order was found despite cigarettes and a lighter being present at the bedside and staff noting the resident needed monitoring during smoke breaks. In another room, an oxygen-dependent resident had a half-full O2 tank left unsecured against the wall instead of in a caddy or stand, and an LPN confirmed the tank should have been secured.
A resident with overactive bladder and recurrent UTI symptoms reported burning with urination and was referred for a urology consult after multiple anti-microbial treatments. The chart showed the referral order, but there was no documentation that the consult was scheduled or completed, and the Director of Transportation confirmed it had not been scheduled.
Unlabeled and Undated Tube Feeding Supplies: A resident’s TF bag was observed with incomplete labeling, and two other residents had undated TF tubing with dated formula in their rooms. An LPN and the ADON confirmed the TF labeling should have included complete information, and the unit nurse verified the undated tubing and dated solution in the residents’ rooms.
Oxygen therapy was not administered as ordered for two residents. One resident with edema and atherosclerotic heart disease was observed receiving O2 at 5 LPM continuously despite an order for 2 to 3 LPM PRN with saturation monitoring, and staff confirmed the mismatch. Another resident with asthma and hypotension was observed with O2 at 3.5 LPM, the cannula not in the nostrils, and a dust-covered concentrator filter; staff confirmed the O2 flow and monitoring were not being carried out as ordered.
Pain medication was administered outside ordered pain-scale parameters for a resident with quadriplegia, a chronic buttock ulcer, and muscle spasms. The resident had an order for PRN oxycodone for severe pain rated 7-10, but the MAR showed doses were given when pain was rated 5 or 6 on multiple occasions. The ADON and DON confirmed staff were expected to follow the physician’s pain-level parameters as written.
Improper Food Storage and Ice Machine Sanitation: Surveyors observed an open bottle of apple cider vinegar stored without a lid in dry storage past its use-by date, along with an open bottle of lemon juice in a reach-in cooler past its use-by date. Surveyors also found an ice machine with a white and brownish film on the inner ice shield and an ice scoop resting on top of the machine instead of in its holder. The Dietary Director acknowledged the storage and sanitation issues.
A resident with severe cognitive impairment was admitted while restrained with abdominal and chest restraints, which were reapplied by an LPN without a physician order or assessment. The restraints confined the resident to bed, and staff failed to follow facility policy requiring immediate removal, assessment, and physician authorization for restraint use. The issue was discovered during a shift change when another LPN assessed the resident and removed the restraints.
A resident with end stage renal disease, muscle weakness, and diabetes, who was dependent on staff for toileting hygiene, had multiple shifts with no documentation that assistance was provided. Staff interviews confirmed that documentation was required each shift, and review found no care plan addressing the resident's incontinence, contrary to facility policy.
A resident with chronic respiratory conditions did not receive BiPAP therapy as ordered due to a missing device component after a room transfer. Nursing staff documented the BiPAP as applied even though it was not used, and the physician was not notified of the issue, resulting in a failure to implement alternative respiratory interventions.
A facility failed to ensure a resident's call light was within reach, posing a potential safety risk. The resident, with a history of falls and muscle weakness, was found without access to the call light, which was placed on an adjacent resident's bedside table. A housekeeper and an LPN confirmed the oversight, and the DON stated that call lights should be accessible to residents.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision. The resident left unnoticed at 3:30 AM, and despite staff interactions, the absence was not reported until much later. A nurse in training falsely documented a refusal of medication, and a CNA failed to report the resident missing, delaying the search. The resident's absence was discovered when a breakfast tray was found untouched, leading to a code white being called.
The facility failed to maintain proper food storage and sanitation practices, with issues such as unlabeled and expired food items, a lack of a handwashing sink in the dining area, and improper reuse of meal trays. The Dietary Supervisor and Infection Preventionist acknowledged these deficiencies, which were contrary to the facility's food storage policy.
A facility failed to develop a care plan for a resident's denture care needs, despite the resident's diagnoses of lack of coordination and dysphagia. The resident was observed eating without dentures and expressed frustration about not receiving assistance to put them on during meals. The care plan lacked documentation for denture assistance, and the DON confirmed it should have been included.
A resident with stage 3 pressure wounds was not repositioned for 15 shifts over a period, despite requiring substantial assistance. The facility's policy required regular repositioning to prevent worsening of pressure ulcers, but this was not adhered to, as confirmed by the DON and Wound Care Nurse.
A resident with severe cognitive impairment and significant weight loss was not provided with 1:1 feeding assistance as per physician's orders. The resident was found with spilled cereal and an untouched meal tray, while staff were unaware of the feeding assistance requirement. Communication breakdown among the interdisciplinary team and staffing issues contributed to the deficiency.
The facility failed to ensure dialysis appointments were not missed and full treatments were completed for two residents due to transportation issues, and did not complete dialysis communication records for three residents. This led to a risk of complications and highlighted lapses in planning and documentation.
A resident with bipolar disorder, anxiety disorder, and major depressive disorder was prescribed Aripiprazole, an antipsychotic medication, but the facility failed to complete the required Abnormal Involuntary Movement Scale (AIMS) assessment upon initiation of the medication. Interviews with staff confirmed that the assessment was not conducted, despite being a standard procedure to monitor for side effects.
Inaccurate Medication Administration and Documentation for Pain and Routine Medications
Penalty
Summary
The deficiency involves failures in accurate medication administration and documentation for two residents, including one with chronic pain and pressure ulcers. One resident had an order for PRN Oxycodone 20 mg every six hours for pain. The MAR showed the Oxycodone as administered early in the morning, but the controlled drug record did not show that the medication was removed from the narcotic supply, and the medication remained in the controlled substance supply. A nursing progress note documented that a family member questioned whether the pain medication had actually been given at the time recorded, and review of the narcotic book and count indicated it had not been administered as documented. The same note recorded that the pain medication was instead administered later that morning due to the timing in the electronic MAR, and family members expressed dissatisfaction with the delay and discrepancy. Interviews and record review confirmed that the Oxycodone had been documented as given in the MAR when it had not been removed from the narcotic supply or administered to the resident. The LPN assigned to the resident during the relevant shift could not recall the resident or the medication error but acknowledged that documenting a medication as administered when it was not given, and while it remained in the controlled substance supply, constituted a medication error that should be reported to a supervisor. The ADON verified that the Oxycodone was documented as administered in the MAR without a corresponding narcotic record entry and confirmed that if the medication remained in supply, it had not been administered. The ADON stated that documentation in the MAR was expected to occur only after the medication was administered and ingested, and that such discrepancies required correction, reporting, and investigation; however, the incident was not reported, did not appear on the 24-hour report, and no investigation or follow-up was implemented. A second deficiency was identified during a medication pass observation for another resident with hypertension, pulmonary embolism, and pneumonia. An LPN prepared this resident’s medications, signed off and saved the MAR indicating the medications were successfully administered, and then proceeded to the bedside to give the medications. The LPN later confirmed that the MAR had been signed off before actual administration, citing familiarity with the resident as the reason, and acknowledged that this practice was inconsistent with facility policy and accepted nursing standards, which require documentation after administration because residents may refuse or not ingest medications. Both ADONs interviewed confirmed that standard practice required verifying the medication against the MAR, preparing and administering the medication, and only then documenting administration, and that documenting prior to administration was not consistent with standard nursing practice. Facility policies on medication errors and administration required accurate, post-administration documentation and timely reporting and investigation of medication errors.
Failure of Governing Body to Oversee Contracted Behavioral Documentation for Medicaid BCCP
Penalty
Summary
The governing body failed to oversee services performed by a contracted vendor responsible for behavior documentation used in Medicaid Behaviorally Complex Care Program (BCCP) applications. Surveyors reviewed Behavior Frequency Documentation Data Sheets for multiple residents and found that behaviors were checked off daily and initialed, but many entries were associated with initials that could not be verified as any facility staff member. The Director of Nursing (DON) stated that facility staff did not have access to these behavior documentation sheets and did not complete them. A Care Coordination Director from the contracted agency reported that their staff completed the documentation based on nursing notes, care plans, meetings, and personal observations, and that this information was used to complete BCCP applications on behalf of the facility, without knowing if anyone at the facility reviewed the applications before submission. For one resident with peripheral vascular disease, COPD, type 2 DM, and a history of TIA, the September 2025 behavior sheets showed daily behaviors and interventions such as token economy systems, loss of privileges, group contingency systems, seating arrangement changes, and frequent movement breaks, all marked as effective. Fourteen entries were initialed with “AB,” an identity that could not be verified, and the DON confirmed these interventions were not part of the resident’s care plan and were not being used by facility staff. Another resident with unspecified dementia, cognitive communication deficit, atherosclerosis of the aorta, and anxiety disorder had behavior sheets listing interventions such as scheduled movement breaks, clear consequences, quiet corner or calming space, student-teacher conferences, school-wide PBIS, behavior tracking apps, classroom jobs, and whole-class reward systems, documented as effective, successful, or somewhat effective, even though these interventions were not approved in the care plan. Additional residents with diagnoses including hemiplegia and hemiparesis after cerebrovascular disease, cerebral infarction, metabolic encephalopathy, bipolar disorder, atrial fibrillation, aneurysm of the carotid artery, atherosclerotic heart disease, schizophrenia, gastrostomy malfunction, hypotension, dementia, morbid obesity, drug-induced akathisia, and abnormal involuntary movements also had behavior sheets with numerous entries initialed by “AB” or otherwise unidentified. For one resident with schizophrenia and movement disorders, interventions such as time-outs, loss of privileges, proximity control, calm down corner, teacher praise, expulsion, detention, and corporal punishment were documented as effective, successful, failed, or ineffective, despite not being approved or used by the facility. The Chief Clinical Officer of the contracted agency reported not noticing any abnormalities in the documentation for these residents and had approved the documentation to be sent with BCCP applications, while the DON verified that the listed interventions did not come from the residents’ care plans and were not being implemented by facility staff.
EBP Signage and PPE Not Used for Residents With Indwelling Devices
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted and that staff wore the required PPE when providing direct care to residents with indwelling medical devices. The report identified this issue for four sampled residents: one resident with a PEG tube, colostomy, and a wound on the left great toe; one resident with a feeding tube; and two residents with gastrostomy tubes. Observations showed that EBP signs were not posted at resident room doors, and PPE such as gowns was not available or not worn during direct care activities. For the resident with a PEG tube, colostomy, and wound, staff were observed entering and leaving the room and providing direct care while no EBP signage was posted and no PPE was available at the door. An LPN stated that residents with indwelling devices such as gastrostomy tubes, IV lines, and urinary catheters required EBP and that PPE should have been worn during direct care, but the LPN was unable to explain the difference between transmission-based precautions and EBP. The Infection Preventionist stated the facility was in the final phase of implementing EBP and was not in compliance at the time of survey. For the resident with a feeding tube, staff observed care being provided without gowns, and multiple nurses stated they were unaware that a gown was required for tube feeding care. One LPN reported bringing the issue to the infection control manager and being told not to worry about it yet, while another nurse stated no formal training had been received. For the two residents with gastrostomy tubes, there was no EBP signage posted, and staff reported that enhanced precautions were not required for tube feeding or that only gloves were needed. The IP confirmed gowns and gloves were required for G-tube care and stated training had not been provided to nurses regarding implementation of the facility's standard and transmission-based precautions program.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a comfortable, homelike environment was maintained for 2 sampled residents and 3 unsampled residents. During a morning tour of the 2200 and 2300 halls, surveyors observed multiple environmental and furniture issues in resident rooms, including broken blinds with missing slats, dresser drawers that were broken and hanging down toward the floor, a dresser missing a middle drawer, and a coaxial cable box in the wall that was missing a cover with cable wires and a splitter hanging out of the wall. One room also had a dresser drawer that was broken and very loose. A maintenance work order for broken blinds and missing slats in one room had been initiated and marked completed on 06/24/2025. On 07/31/2025, the Maintenance Director reported no knowledge of the broken blinds, broken furniture, or uncovered coaxial cable holes in the wall, although he stated open holes in walls should be covered. He agreed the rooms were not currently presented as a home-like environment. The ADON for the 2200 and 2300 halls was also unaware of the broken blinds, broken furniture, or uncovered coaxial cable holes in the wall and stated that if the issues had been known, work orders would have been submitted. The ADON confirmed these items should be continually maintained like a homelike environment. The facility's Resident Rights Policy stated residents had a right to a safe, clean, comfortable, and homelike environment.
Failure to Notify Mental Health Authority After Psychiatric Change
Penalty
Summary
The facility failed to ensure the state mental health authority was notified after a significant change in the mental health condition of a resident with a history of mental health disorder. Resident 12 was admitted with diagnoses including schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and anxiety disorder. The admission paperwork noted the resident had been sent from a nursing facility to the Emergency Department on a legal hold after becoming homicidal toward other residents, and the resident was later transferred back to a skilled nursing facility after being deemed no longer suicidal or homicidal and tolerating medications well. A review of the resident’s hospital behavioral health notes and discharge documentation showed the resident had previously diagnosed psychiatric conditions and experienced a change in condition that led to homicidal behavior, with possible post-traumatic stress related to a prior assault. The PASARR level one document dated 08/09/2018 indicated dementia but no other mental illness, intellectual disability, mental retardation, or related condition, and the resident was deemed appropriate for nursing facility placement. The Director of Social Services stated that a PASARR level two referral should have been completed because the resident had a legal discharge due to a psychiatric change in condition, but the medical record lacked documentation that a PASARR level two screening referral was completed.
Missing smoking assessment and unsecured oxygen tank
Penalty
Summary
A smoking safety assessment was not completed for a resident admitted with contracture of muscles at multiple sites and muscle weakness who was documented as a smoker. On 07/29/2025, the resident was observed in bed with a pack of cigarettes and a lighter visible at the bedside table, and the resident stated being able to smoke independently despite impaired mobility in both hands. The resident later went out in a geri-chair for a smoke break, and the accompanying CNA stated the resident could handle a cigarette with the right hand and would need monitoring to ensure safety. The resident’s physician admission note and subsequent physician notes documented that the resident was a smoker, but the medical record lacked evidence of a smoking safety assessment and a physician order. An LPN stated the admission nurse was responsible for asking whether a new resident smoked and that a smoking assessment should have been completed if the resident wanted to smoke, and the ADON confirmed no smoking assessment was completed. An oxygen tank was also found unsecured in a resident room for a resident with atherosclerotic heart disease and chronic kidney disease who was receiving oxygen 1.5 liters via nasal cannula from an oxygen concentrator and stated being on oxygen around the clock and using an oxygen tank when in a wheelchair. On 07/29/2025, a half-full oxygen tank was observed against the wall at the foot of the bed without a stand, caddy, or other secure fixture. An LPN confirmed the tank should have been placed on an oxygen caddy and acknowledged that an unsecured oxygen tank was very dangerous and could severely hurt someone. The ADON later confirmed that oxygen should be in a caddy even when in storage, and the facility policy stated that small cylinders should always be placed in a stand or cart.
Urology Consult Not Scheduled After Physician Order
Penalty
Summary
The facility failed to ensure that a physician-ordered urology consultation was arranged for a resident with overactive bladder and morbid obesity who had a history of frequent urinary tract infections. The resident was admitted on [DATE] and, during an interview on 07/29/2025, stated that he or she had just finished antibiotics for a UTI, was concerned about taking too many antibiotics, and had been waiting to hear from staff about the ordered urologist consult. Record review showed that on 05/23/2025 the resident reported burning with urination, which was reported to the NP. The NP documented that the resident had been treated with different anti-microbials and authorized a referral to a urologist. The physician order for referral to urologist had no directions specified, and a progress note on 05/26/2025 documented continued burning with urination and a new order to collect urine for analysis, with instructions to notify the physician if symptoms worsened. The medical record did not document that the urology consultation was scheduled or completed, and on 07/31/2025 the Director of Transportation confirmed the consult had not been scheduled.
Unlabeled and Undated Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure tube-feeding formula bags and tubing were labeled for 3 of 35 sampled residents: R118, R251, and R222. R118 was admitted and later readmitted with diagnoses including epilepsy and anoxic brain damage. On 07/29/2025 at 10:36 AM, R118’s TF bag was observed unlabeled except for the date 07/28/2025. On 07/31/2025 at 1:38 PM, the TF bag was labeled with the resident’s name, date, and time, but it did not include the TF rate or nurse initials. At 2:25 PM the same day, an LPN stated the TF bag should have been completely labeled with formula, TF rate, resident’s name, room number, nurse initials, date, and time, and at 2:26 PM the ADON stated the TF should have been completely labeled. R251 was re-admitted with diagnoses including cognitive communication deficit, metabolic encephalopathy, dementia, altered mental status, unspecified intellectual disabilities, and generalized anxiety disorder. On 07/29/2025 in the morning, R251 had a feeding tube pump in the room, and the tube feeding line was not dated; the date on the tube feeding solution was 07/27/2025. R222 was re-admitted with diagnoses including seizures, anxiety disorder, depression, and lack of expected normal physiological development in childhood. On 07/29/2025 in the morning, R222 was attached to an active feeding tube line that was not dated. That same morning, the unit nurse verified the 07/27/2025 date on the feeding tube solution and the undated tubing in the rooms of R251 and R222. On 07/31/2025 at 08:28 AM, the LPN described that the date and time had to be checked for the entire system and that it needed to be replaced every 24 hours, including noting the date and time on the formula and on the tubing lines after the formula was hung and the tubes were changed.
Oxygen Therapy Not Administered or Maintained as Ordered
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for two residents and failed to clean an oxygen concentrator filter for one resident. One resident with diagnoses including edema and atherosclerotic heart disease had a physician order to receive O2 at 2 to 3 LPM via nasal cannula as needed for O2 saturation below 90% to maintain saturation above 90%, but the medical record lacked documented evidence that oxygen administration and saturation were being monitored. During observations, the resident was found in bed confused with O2 flowing at 5 LPM via nasal cannula, and later continued to be observed with O2 continuously flowing at 5 LPM. An LPN and the ADON both confirmed the resident’s O2 was flowing at 5 LPM continuously when the order was for 2 to 3 LPM. Another resident with diagnoses including asthma and hypotension had a physician order for O2 at 2 LPM via nasal cannula as needed and a care plan directing staff to administer and monitor O2 as ordered. During observations, the resident’s oxygen was flowing at 3.5 LPM via nasal cannula, the cannula was not positioned in the nostrils, and the oxygen concentrator filter was covered with dust. The same findings were repeated on later observations, and an LPN confirmed the oxygen was flowing continuously at 3.5 LPM when the order was for 2 LPM PRN. The LPN also stated there was no order in place for cleaning the filter, and the Discharge Planner confirmed O2 saturation was not monitored and the liter flow was not administered as ordered.
Pain medication given outside ordered pain-scale parameters
Penalty
Summary
The facility failed to ensure the ordered pain-scale parameters were followed for one sampled resident. Resident 8 was admitted with diagnoses including quadriplegia, a non-pressure chronic ulcer of the buttock, and muscle spasms. On 07/29/2025, the resident stated having frequent pain with a pain scale of 7-10 and reported that pain medication was administered as needed. A physician order dated 12/20/2022 directed Oxycodone Hydrochloride 10 mg by mouth every 4 hours as needed for severe pain level 7-10. The Medication Administration Record showed Oxycodone was administered when the resident’s pain level was below the ordered range on multiple dates in July 2025, including pain levels of 5 and 6 with medication given once or twice per day. The ADON stated nursing staff were expected to follow physician orders as written for PRN pain medication and that medication was not to be given if the reported pain level was below 7; the nurse was to notify the provider to clarify or adjust the order or request an alternative pain management intervention. The DON also confirmed staff were expected to follow the pain level parameters as prescribed. A facility policy titled Pain Management stated the goal of the pain management program was to ensure pain was identified and treated effectively and consistently.
Improper Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to ensure foods were stored properly and that ice machines were cleaned in 1 of 2 ice makers in the facility. On 07/29/2025 in the morning, surveyors observed an open bottle of apple cider vinegar without a lid in the dry food storage area with a use-by date of October 19, 2024. In the reach-in cooler, there was also an open bottle of lemon juice with a use-by date of July 20, 2025. At 8:34 AM, the Dietary Director stated the apple cider vinegar should not have been stored without a lid and that both the lemon juice and apple cider vinegar should have been discarded on or before the use-by date. On 07/31/2025 in the morning, surveyors observed an ice machine in the B building back auxiliary hall closet with a white and brownish film on the bottom of the inner ice shield, and the plastic ice scoop was resting on top of the machine. At 10:26 AM, the Dietary Director stated the ice machines were cleaned periodically and had been recently cleaned, and stated the ice scoop should be in a holder on the side of the machine. The facility’s Food and Nutrition Services policy stated food and beverage storage, preparation, distribution, and service were to be conducted under sanitary conditions, and the Food Storage and Retention Guide referenced the FDA 2017 Food Code regarding use-by dates.
Resident Restrained Without Physician Order or Assessment
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was admitted to the facility while restrained with abdominal and chest restraints. Upon admission, the admitting nurse untied the restraints to transfer the resident to the facility bed and then reapplied the restraints, confining the resident to the bed. The nurse did not obtain a physician order for the use of these restraints, nor was an assessment conducted to determine the necessity or safety of the restraint use as required by facility policy. During the evening, a CNA questioned the use of the restraints and was instructed by the LPN to keep the restraints in place after providing care, citing a lack of time to check on the resident frequently. Video review confirmed that the LPN did not check on the resident until several hours later, during the early morning medication pass. At shift change, the incoming LPN was not informed about the restraints and only discovered them during an assessment, at which point the restraints were immediately removed due to the absence of a physician order. Interviews with facility leadership and nursing staff confirmed that the general practice is to avoid the use of restraints and that any resident arriving with restraints should have them removed immediately pending assessment and physician evaluation. The admitting nurse acknowledged being aware of the restraints and applying them without proper authorization or assessment, which was corroborated by video evidence and staff interviews.
Failure to Document and Provide Assistance with Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide documented evidence that assistance with activities of daily living (ADL), specifically toileting hygiene, was provided for one resident who was dependent on staff for this care. The resident in question was admitted with diagnoses including end stage renal disease, muscle weakness, and type 2 diabetes mellitus, and was assessed as frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. Review of the resident's ADL documentation revealed multiple shifts across several days where there was no documentation that toileting hygiene was performed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the expectation was for staff to document toileting hygiene every shift, and that blank documentation indicated the task was not performed. Further review showed that the resident did not have a care plan addressing incontinence, despite being assessed as dependent and frequently incontinent. The facility's policy required CNAs to assist residents with ADLs and to document care accurately and timely. The lack of documentation and absence of a care plan for incontinence indicated that the required assistance with toileting hygiene may not have been provided as needed for this resident.
Failure to Follow Physician Orders for BiPAP Application Due to Missing Equipment
Penalty
Summary
The facility failed to follow physician orders for the application of a BiPAP device for a resident with a history of acute on chronic hypercapnic respiratory failure, COPD exacerbation, and chronic hypoxic respiratory failure. The resident was ordered to use BiPAP during sleep, with staff assistance for setup and documentation of any refusal. However, after a room transfer, a critical component of the BiPAP device (elbow connector) was lost, making the device unusable for two nights. During this period, the resident received oxygen via nasal cannula instead, as per physician orders, but the BiPAP was not applied as ordered. Nursing staff documented in the Medication Administration Record and progress notes that the BiPAP was applied, despite the device being inoperable due to the missing part. The attending physician was not notified about the inability to use the BiPAP, and no alternative respiratory interventions were implemented. The Director of Nursing confirmed that the missing connector was not reported to the physician and acknowledged that documentation inaccurately reflected the use of the BiPAP device.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light buttons were within reach of a resident, leading to a potential safety risk. A resident, who was admitted with diagnoses including secondary malignant neoplasm of bone, generalized muscle weakness, and repeated falls, was observed lying in bed without the call light within reach. The call light button was found on the bedside table of an adjacent resident. A housekeeper confirmed the call light was not accessible to the resident. An LPN acknowledged that the call light should have been within the resident's reach, especially since the resident was a fall risk. The Director of Nursing also stated that call lights should be placed within the reach of residents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment, leading to the resident's elopement. The resident, diagnosed with bipolar disorder and dementia, was able to leave the facility unnoticed at approximately 3:30 AM. Despite multiple staff interactions, including a nurse in training and a CNA, the absence of the resident was not reported or addressed until much later. The nurse in training incorrectly documented that the resident refused medication, and the CNA did not report the resident missing, which delayed the initiation of a search. The resident's absence was not discovered until a breakfast tray was found untouched at around 8:50 AM, prompting a search and a code white being called at 9:52 AM. Interviews with staff revealed that rounds were supposed to be conducted every 2-3 hours, and residents were generally seen more frequently. However, the staff failed to verify the resident's location, leading to a significant delay in recognizing the elopement. The facility's policy on elopement was not followed, as staff did not promptly report the missing resident to a supervisor.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition and did not ensure that food items stored in the reach-in refrigerator and freezer were labeled, dated, and not expired. During an initial tour of the kitchen, significant dust buildup was observed on vents and light fixtures over the food preparation area. Damaged cans of beans and mushrooms were found in the dry storage room, and a fan in the walk-in freezer lacked a blade cover. In the walk-in refrigerator, a bowl containing lettuce, cheese, and tomato was not labeled or dated. Additionally, several containers in the reach-in refrigerator, including those with boiled eggs, chopped meat, and blue cheese, were either not labeled, not dated, or expired. A container of potato with egg salad was also expired, and two bowls of pre-made salad were not dated. A squirt bottle containing cleaning chemicals in the storage room was not labeled. In the main dining area, a satellite setup for warming and keeping food at temperature was used without a handwashing sink, posing a risk to infection control practices. The Dietary Supervisor acknowledged the lack of a sink and the improper practice of reusing trays that had been served to residents. The Infection Preventionist confirmed that it was unacceptable to reuse trays and emphasized the importance of proper handwashing etiquette. Despite being advised to stop using the satellite area until a sink was installed, the facility staff continued to use it for meal service. The facility's policy on food storage emphasized the need for proper labeling, dating, and storage to prevent contamination, which was not adhered to in this instance.
Failure to Address Denture Care Needs in Resident's Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the denture care needs for Resident 15, who was admitted with diagnoses including lack of coordination and dysphagia. On a specific date, Resident 15 was observed eating breakfast without their dentures, which were needed to assist with chewing and swallowing due to their medical conditions. The resident expressed frustration about not receiving help to put on their dentures during meal times, which limited their food and eating options. The care plan for Resident 15, revised earlier in the year, indicated a need for assistance with personal hygiene and oral care but did not include specific interventions for denture assistance. The Minimum Data Set (MDS) coordinator stated that any oral or dental needs should be included under oral care and hygiene in the care plan, and acknowledged that the nursing staff could individualize the care plan to include denture care. However, the care plan lacked documentation for denture assistance, and the Director of Nursing confirmed that the care plan should have included denture use to ensure it was reflected on the point of care flowsheets used by certified nursing assistants.
Failure to Provide Adequate Pressure Ulcer Preventative Measures
Penalty
Summary
The facility failed to provide adequate pressure ulcer preventative measures for a resident, identified as Resident 246, who was admitted with stage 3 pressure wounds on the right heel, right lower extremity, and coccyx. The Minimum Data Set indicated that the resident required substantial to maximal assistance for repositioning. Despite this need, the review of the turning and repositioning flowsheet revealed that the resident was not repositioned for 15 shifts over a period from February 20, 2024, to March 11, 2024. Specific dates included multiple night shifts and one day shift where repositioning did not occur. The facility's policy, revised in December 2023, stated that residents with pressure ulcers should receive necessary treatment and services to promote healing and prevent new pressure injuries, which includes regular repositioning. The Wound Care Nurse emphasized the importance of repositioning every two hours to prevent the worsening of pressure ulcers. However, the Director of Nursing acknowledged that the care staff failed to reposition the resident as required, and the documentation did not reflect the necessary care actions.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to provide a resident, identified as Resident 114, with 1:1 feeding assistance as per the physician's order. This deficiency was observed when Resident 114, who had severe cognitive impairment and was on a renal dysphagia pureed diet, was found sitting in a hallway with spilled cereal on their clothes and an untouched breakfast tray nearby. The resident's meal ticket did not include any assistance instructions, and staff members present were either unfamiliar with the resident or unaware of the need for feeding assistance. The resident had a history of significant weight loss, with documented undesired weight loss in several months leading up to the incident. Despite a physician's order and speech therapy recommendations for 1:1 feeding assistance due to the resident's need for maximum cueing to safely consume meals, the facility's staff did not provide the necessary assistance. The Registered Nurse and Certified Nursing Assistant on duty were not aware of the resident's needs, and the Assistant Director of Nursing was under the impression that only tray setup and supervision were required. The Registered Dietitian's nutritional assessments did not align with the physician's order, indicating a breakdown in communication among the interdisciplinary team. The Director of Nursing acknowledged the discrepancy and confirmed that the staff did not follow the physician's order or the resident's nutrition care plan. The deficiency was further exacerbated by staffing issues on the day of the observation, with several staff members calling off work, leading to inadequate coverage and assistance for Resident 114.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that dialysis appointments were not missed and that full treatment was completed for two residents, leading to a risk of complications such as fluid overload and uremia. Resident 114 missed a dialysis appointment due to the facility's inability to provide transportation, as one driver was on vacation and another called off work. Additionally, Resident 114 arrived late to another appointment, resulting in incomplete treatment because the transportation driver could not wait for the session to finish. The facility did not communicate with the dialysis provider about the missed appointment, and there was no documented physician response regarding the missed session. Resident 220 also missed a dialysis appointment due to transportation issues on the same day as Resident 114. The facility had contracted two transport companies to assist when drivers were unavailable, but the contracted company could only accommodate three out of five residents needing transport that day. The Director of Transportation confirmed that the request for additional transport was made too late to be accommodated, highlighting a lack of planning and communication within the facility. Furthermore, the facility failed to complete dialysis communication records for three residents, which are essential for ensuring proper communication between the facility and the dialysis center. The records were missing for specific dates for Residents 176, 113, and 126. The facility's policy required ongoing communication and documentation related to pre- and post-dialysis care, but this was not adhered to, as evidenced by the missing records. The Medical Records Director confirmed the absence of these records, indicating a lapse in the facility's documentation process.
Failure to Complete AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the completion of the Abnormal Involuntary Movement Scale (AIMS) assessment for a resident, identified as Resident 15, who was receiving antipsychotic medication. Resident 15 was admitted with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder. The resident was prescribed Aripiprazole, an antipsychotic medication, to be taken orally twice a day for mood changes. However, the resident's medical record did not contain documented evidence of an AIMS assessment being completed upon the initiation of this medication. Interviews with facility staff confirmed the deficiency. The Medical Records Director acknowledged the absence of the AIMS assessment in the resident's electronic health record. The Director of Staff Development and the Director of Nursing both indicated that an AIMS assessment should be conducted when an antipsychotic medication is initially ordered and then every six months thereafter. The Assistant Director of Nursing also confirmed the responsibility for ensuring the completion of the AIMS assessment upon admission and when antipsychotic medication is ordered. Despite these expectations, the assessment was not completed for Resident 15, highlighting a lapse in the facility's protocol for monitoring potential side effects of antipsychotic medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tlc Care Center | 5 mi | ★★★★★ | 6 | 0 |
| Advanced Health Care Of Paradise | 6.8 mi | ★★★★★ | 7 | 0 |
| Oasis Nursing & Rehab Of Green Valley | 8.1 mi | ★★★★★ | 20 | 0 |
| Nevada State Veterans Home - Boulder City | 8.1 mi | ★★★★★ | 13 | 0 |
| Green Valley Health And Wellness Suites | 9.1 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.