Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Center during CMS and state inspections, most recent first.
Failure to document and administer ordered antibiotic: A resident with uropathy, BPH, and CKD had an order for Gentamicin 80 mg IM daily x 3 days for UTI, but the MAR did not show one of the doses as given. The facility policy required meds to be administered as ordered and documented on the MAR, and the DON stated missed or held doses should also be documented and the MD notified.
Failure to Monitor Weight Loss and Provide Timely Nutritional Interventions: The facility did not follow its weight system policy or timely address significant weight loss for two residents. One resident with Alzheimer’s Disease, dysphagia, and total dependence for meals lost 10.9% of body weight in 35 days, and another resident with dementia, diabetes, and HTN lost 9.52% in 29 days; in both cases, nutritional interventions were not ordered until later, and the DON acknowledged they should have been implemented sooner.
Failure to follow oxygen orders and document oxygen therapy for two residents. One resident with CHF, anemia, A-fib, and Alzheimer's had an order for 2 L NC PRN for SOB, but the MAR did not document oxygen use and observations showed oxygen being used at varying settings. Another resident with cervical myelopathy, pleural effusion, and emphysema had an order for 2 L NC PRN for SOB and comfort, but the MAR did not document oxygen use and the concentrator was observed set at 1.5 L instead of 2 L; an LPN and the DON confirmed the ordered setting.
The facility failed to maintain sanitary conditions in food storage, preparation, and service areas, with multiple instances of unlabeled, undated, and expired food items, mold and debris in ice chests and the kitchen ice machine, and incomplete cleaning schedules for key equipment. Staff interviews revealed inconsistent cleaning practices and a lack of oversight, resulting in unsanitary conditions affecting nearly all residents receiving meals.
The facility failed to maintain residents' dignity during dining as staff used informal terms like 'honey' and 'baby' instead of courtesy titles, and referred to residents as 'feeders.' Additionally, staff did not knock or announce themselves before entering rooms, breaching residents' privacy. The DON confirmed these actions were against policy.
The facility failed to provide appropriate respiratory care for two nurses observed for tracheostomy care and did not obtain a physician's order for a resident's oxygen use. RN F and LPN C did not perform hand hygiene as required, and RN F did not clean a resident's trach site. Additionally, a resident was administered oxygen without a physician's order, which was acknowledged by LPN T and confirmed by the DON.
A long-term care facility failed to maintain accurate medication records and reconcile controlled medications, leading to discrepancies in medication counts and improper handling. A resident's Morphine bottle contained an unexpected clear liquid, and other medications like Diazepam and Lyrica had discrepancies in their counts. The DON confirmed these issues, indicating a failure in the facility's medication management system.
A LTC facility reported a 34.48% medication error rate involving three nurses. Errors included improper IV flushes and unauthorized cocktailing of medications for residents with complex medical conditions. The DON confirmed the need for adherence to physician orders.
The facility failed to maintain proper infection control practices, with CNAs not performing hand hygiene and LPNs neglecting enhanced barrier precautions and equipment cleaning. CNAs handled residents' food without gloves, and LPNs did not use PPE or clean stethoscopes and blood pressure cuffs between uses. The DON confirmed the need for hand hygiene and equipment cleaning, revealing deficiencies in the facility's infection prevention program.
The facility failed to ensure proper and secure storage of medications, as observed with two LPNs who left medications unattended and unsecured on medication carts. One LPN left Baclofen unattended while donning PPE and later unsecured on an overbed tray, while another left Bupropion unattended while searching for a computer outlet. Both LPNs acknowledged the error, and the DON confirmed the requirement for medications to be in sight of the nurse.
The facility failed to properly store food in resident nourishment refrigerators, with multiple items found unlabeled, undated, or expired. Additionally, alcohol was improperly stored without a care plan or order. Staff interviews confirmed these practices were against facility policy, and the DON acknowledged the lack of an alcohol storage policy.
Failure to Document and Administer Ordered Antibiotic
Penalty
Summary
The facility failed to follow a physician’s order for Resident #13, who was admitted with diagnoses including uropathy, benign prostatic hyperplasia, and chronic kidney disease. A physician ordered Gentamicin Sulfate Solution 80 mg IM once daily for 3 days for a UTI, but the July 2025 MAR did not document the medication as administered on 7/31/2025. The facility policy reviewed stated that medications are to be administered by licensed nurses as ordered by the physician and documented on the MAR after administration. Resident #13’s quarterly MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. During interview, the DON stated that if Gentamicin IM was ordered once daily for 3 days, the resident should receive all 3 doses, that medications should be documented when administered, that they should also be documented if not given or held, and that the physician should be notified if a medication dose was missed.
Failure to Monitor Weight Loss and Provide Timely Nutritional Interventions
Penalty
Summary
The facility failed to accurately assess residents’ nutritional status, follow its weight-monitoring policy, and provide timely nutritional interventions for 2 of 4 residents reviewed for nutrition. The facility policy titled, Weight System, required weekly weights for significant weight changes, review of weekly and monthly weights by the DON or designee, reweights when changes exceeded set thresholds, discussion of residents with significant weight loss or gain, referral to the RD for significant weight changes, and implementation of interventions as needed. The policy also stated that residents with significant weight loss or gain of 5% in 1 month would be weighed weekly for four weeks or longer if not stable. One resident with diagnoses including Alzheimer's Disease, Encephalopathy, Dysphagia, and Anxiety had a quarterly MDS showing moderate cognitive impairment and total dependence for meals, with weight loss coded as 5% in the last month and over 10% in the last 6 months. Her weight dropped from 119 pounds to 106 pounds in 35 days, a 10.9% loss, but the documented intervention of fortified food at dinner and a 120 mL house supplement at bedtime was not ordered until months later. Another resident with diagnoses including Dementia, Diabetes, and Hypertension had a quarterly MDS showing moderate cognitive impairment. Her weight decreased from 145 pounds to 131.2 pounds in 29 days, a 9.52% loss, but the order for High Calorie Boost twice daily was not documented until after the weight loss was identified. The DON stated that interventions should have been implemented earlier for both residents.
Failure to Follow Oxygen Orders and Document Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and document oxygen therapy for 2 residents reviewed for respiratory care. Resident #42 had diagnoses including Congestive Heart Failure, Anemia, Atrial Fibrillation, and Alzheimer's disease, and had a physician order for 2 liters by nasal cannula for shortness of breath as needed. The quarterly MDS showed a BIMS score of 9 and did not code the resident for oxygen use. The MAR did not document oxygen use from 11/1/2025 through 11/18/2025, yet a progress note on 11/16/2025 documented binasal cannula on 1 1/2 liters, and an observation on 11/18/2025 found the resident receiving 2 liters of oxygen via portable tank. An LPN stated the resident's oxygen should be set at 1 1/2 to 2 liters and that oxygen use should be documented on the MAR. Resident #75 had diagnoses including Cervical Myelopathy, Pleural Effusion, and Emphysema, with a physician order for 2 liters by nasal cannula for shortness of breath and comfort as needed every 1 hour. The quarterly MDS showed a BIMS score of 6 and did not code the resident for oxygen use. The MAR did not document oxygen use from 11/1/2025 through 11/18/2025. Observations on 11/17/2025 and 11/18/2025 showed the resident receiving oxygen via nasal cannula with the concentrator set at 1.5 liters per minute. During interview, an LPN acknowledged the concentrator was set incorrectly and should have been set at 2 liters per minute, and the DON confirmed the resident should be receiving oxygen at 2 liters per minute.
Widespread Food Storage and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, as evidenced by multiple observations and interviews. Food items in the cooler and dry storage were found to be unlabeled, undated, and in several cases, expired. Opened containers of food and beverages, such as apple juice, milk, and buttermilk, were stored without proper labeling or dating, and expired seasonings, cereals, and other food products were present in dry storage. The walk-in cooler and dry storage areas also contained loose and dried debris, and food containers were visibly soiled. Sanitation issues extended to equipment and utensils used for food and ice distribution. Ice storage chests on multiple halls were observed to have mold-like substances inside and outside, and the containers holding ice scoops contained a white slimy residue. The kitchen ice machine, used for both food preparation and resident consumption, had rust-like debris and black powdery mold-like substances inside the bin, with ice scoops resting in unsanitary conditions. Tray carts used to transport meal trays had dried debris and rust spots, and the floor mixer had grease oozing from a control knob above the mixing bowl. Cleaning schedules for these items were either incomplete or not documented as completed, and staff interviews revealed a lack of consistent cleaning practices for ice chests and other equipment. The facility's infection prevention and dietary oversight were also lacking. The Infection Preventionist had not completed required audits for approximately a year and could not provide documentation of previous in-services related to infection control. The maintenance director and administrator confirmed that the ice machine had not been cleaned or sanitized according to the manufacturer's guidelines for at least a year. Staff interviews indicated a lack of awareness or adherence to cleaning schedules for ice chests and other food service equipment, and the Registered Dietician was unaware of the lapse in cleaning and sanitizing the ice machine. These failures resulted in unsanitary conditions for food storage, preparation, and service, affecting nearly all residents receiving meals from the kitchen.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to uphold residents' dignity and respect during dining, as observed by surveyors. Seven out of fifteen staff members, including CNAs, an LPN, and an RN, did not adhere to the facility's policy on addressing residents with courtesy titles. Instead of using formal titles like Mr. or Mrs., staff members used informal and potentially disrespectful terms such as 'darling,' 'honey,' 'sweetheart,' 'sweet pea,' and 'baby' when addressing residents. Additionally, some staff referred to residents as 'feeders,' which is not in line with maintaining residents' dignity. Furthermore, staff members failed to knock or announce themselves before entering residents' rooms, which is a breach of the residents' right to privacy and respect. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged that staff should not refer to residents with informal terms or enter rooms without knocking or announcing themselves. These actions and inactions by the staff members led to the deficiency in maintaining or enhancing residents' dignity and respect during dining.
Deficiencies in Respiratory Care and Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care and services consistent with professional standards of practice for two nurses observed for tracheostomy care and failed to obtain a physician's order for a resident reviewed for respiratory care. The facility's policy on tracheostomy care mandates that care be provided according to physician orders and that staff perform hand hygiene before and after care. However, during observations, RN F did not perform hand hygiene before donning gloves and failed to clean mucus from a resident's tracheostomy site, trach collar, and remove a soiled towel. Additionally, RN F exited the room without performing hand hygiene. Similarly, LPN C did not perform hand hygiene before donning gloves during tracheostomy care, despite the presence of a fan that could potentially spread contaminants. The medical record review revealed that Resident #276, who was cognitively intact, had a physician's order for tracheostomy care every shift. However, the care provided by RN F did not adhere to the facility's policy or professional standards, as evidenced by the failure to clean the trach site and perform hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed before and after glove use and that trach care should include cleaning the trach site. For Resident #36, who was severely cognitively impaired, the facility failed to obtain a physician's order for oxygen administration. Observations showed the resident wearing a face mask connected to an oxygen concentrator set at 5.5 liters per minute, but there was no physician's order for this treatment. LPN T acknowledged the absence of an order and stated it should have been entered over the weekend. The Director of Nursing confirmed that oxygen should not be administered without a physician's order.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled medications in several medication storage areas and for multiple residents. The facility's policy on controlled substance accountability was not adhered to, as evidenced by discrepancies in medication counts and improper handling of medications. For instance, a bottle labeled as Morphine for a resident contained a clear liquid instead of the expected blue solution, and the bottle lacked a seal. This discrepancy was confirmed by the Director of Nursing (DON) and the pharmacist, indicating a failure in the facility's medication management system. Further observations revealed improper handling of medications, such as a Diazepam card with doses taped closed instead of being properly wasted. The DON confirmed that this practice was against the facility's policy. Additionally, there were discrepancies in the controlled drug records for several residents, with mismatches between the recorded and actual remaining amounts of medications like Lyrica, Hydrocodone, Gabapentin, and Alprazolam. These discrepancies were not accounted for, and the nursing staff failed to document the administration of controlled substances accurately. The report highlights multiple instances where the facility's staff did not follow proper procedures for medication reconciliation and documentation. The DON acknowledged the issues, including the lack of a seal on the Morphine bottle and the failure to document controlled substance administration correctly. These findings indicate a systemic issue in the facility's management of controlled medications, leading to potential risks for residents due to inaccurate medication records and handling.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a total of 10 errors observed out of 29 opportunities, resulting in a 34.48% error rate. The errors involved three nurses, including two LPNs and one RN, who did not adhere to physician orders and facility policies during medication administration. The facility's policies on medication administration, including those for enteral tubes and intravenous therapy, were not followed, leading to multiple medication errors. One resident, diagnosed with encephalopathy, asthma, meningococcal infection, dysphagia, and hypertensive heart disease, was involved in two medication errors. The RN administered a Heparin flush before an Ampicillin IV infusion instead of the required Normal Saline flush, and failed to administer the Normal Saline flush before the infusion. Another resident, with diagnoses including a right foot ulcer, sepsis, diabetes, and a staphylococcus infection, experienced a medication error when an LPN did not follow the physician's order to flush the PICC line with Heparin after a Normal Saline flush. A third resident, with conditions such as cerebral infarction, hypertension, diabetes, depression, and respiratory failure, was involved in seven medication errors. An LPN crushed and combined seven medications into one cup and administered them via a PEG tube without a physician's order to cocktail the medications. The Director of Nursing confirmed that the nurses should have followed the physician's orders and that medications should not be cocktailed without specific orders.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple staff members not adhering to hand hygiene protocols and enhanced barrier precautions. Certified Nursing Assistants (CNAs) L, N, and O were observed during dining service failing to perform hand hygiene after handling items in the environment and before handling residents' food. CNA L did not perform hand hygiene between resident contacts and after handling environmental objects, while CNA N and CNA O touched residents' food with bare hands without performing hand hygiene or wearing gloves. Interviews with the CNAs revealed a lack of understanding of the facility's hand hygiene policy. Additionally, the facility's Licensed Practical Nurses (LPNs) failed to observe enhanced barrier precautions and clean reusable equipment during medication administration. LPN C did not apply personal protective equipment (PPE) when administering IV medication to a resident under enhanced barrier precautions, despite acknowledging the requirement to do so. Furthermore, LPN B and LPN C did not clean their stethoscopes before or after use on residents, and LPN B failed to clean a blood pressure cuff between uses on different residents. These actions were contrary to the facility's policy on cleaning and disinfection of resident-care equipment. The Director of Nursing (DON) confirmed that staff should perform hand hygiene before and after donning and doffing gloves and that PPE should be worn with enhanced barrier precautions for residents with tubes, artificial lines, wounds, or openings. The DON also acknowledged that reusable equipment should be cleaned between uses on residents. The failure to adhere to these infection control practices was observed during interviews and reviews of the facility's policies, highlighting a deficiency in the facility's infection prevention and control program.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly and securely stored, as observed with two LPNs on separate occasions. The facility's policy mandates that all drugs and biologicals be stored in locked compartments or under the direct observation of the administering nurse. However, LPN C left a medication cup with crushed Baclofen unattended on the 600 Hall Medication Cart while donning PPE and later left medications unsecured on an overbed tray while washing hands in a resident's bathroom. Similarly, LPN B left a medication cup with Bupropion unattended on the 400 Hall Medication Cart while searching for an outlet for the computer. Both LPNs acknowledged that medications should not be left unattended and unsecured, and the DON confirmed that medications should always be in sight of the nurse.
Improper Food Storage and Alcohol Management in Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper storage of food items in the resident nourishment refrigerators, as evidenced by the presence of unlabeled, undated, and expired items. The facility's policy requires that all food items brought in by family or visitors must be labeled and dated, and any items not consumed within three days should be discarded by the staff. However, observations in two different nutrition rooms revealed multiple items, including ice cream, orange juice, breakfast croissants, milk, and various other food products, that were either unlabeled, undated, or expired. Additionally, a six-pack of alcoholic beverages was found in one of the refrigerators, with only one bottle remaining, and there was no care plan or order for the resident associated with the alcohol. Interviews with staff, including two LPNs, the Director of Nursing (DON), and the Certified Dietary Manager, confirmed that the items in the nourishment refrigerators should be labeled and dated, and that alcohol should not be stored in these refrigerators. The DON acknowledged that alcohol for residents should be care planned and ordered, and should be stored like narcotics, requiring it to be signed out. Furthermore, the facility did not have an existing policy for the storage of alcohol for residents, as confirmed by the DON.
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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) |
|---|---|---|---|---|
| Laurelwood Health Care Center | 15.2 mi | ★★★★★ | 5 | 1 |
| Mission Convalescent Home | 16.3 mi | ★★★★★ | 0 | 0 |
| Cypress Grove Post Acute | 17.5 mi | ★★★★★ | 0 | 0 |
| West Tennessee Post Acute | 17.6 mi | ★★★★★ | 0 | 0 |
| Selmer Post Acute | 18.7 mi | ★★★★★ | 0 | 0 |
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