Inspection Reports for Henderson Health and Rehab

The facility was found deficient in multiple areas including maintaining a homelike environment, notifying appropriate authorities for significant mental health changes, completing smoking safety assessments, securing oxygen tanks, scheduling specialist consultations, labeling feeding tube supplies, administering oxygen as ordered, following pain management orders, proper food storage, and implementing enhanced barrier precautions for infection control.

Complaint #NV00073441 regarding improper use of restraints, failure to provide ADL assistance, and failure to follow respiratory care orders.

The facility failed to ensure a resident was free from physical restraints without physician orders, failed to provide documented assistance with activities of daily living for an incontinent resident, and failed to follow physician orders for the application of a BiPAP device for a resident with respiratory failure. These deficiencies placed residents at risk of physical, psychosocial harm, compromised skin integrity, and respiratory complications.

There were eight complaints and one FRI investigated. Three complaints and the FRI were substantiated, some with regulatory deficiencies and some without. Several complaints were unsubstantiated. The investigation included interviews with multiple staff and residents, clinical record reviews, and document reviews.

The investigation included observations, interviews, and document reviews. Several deficiencies were identified related to physical restraints, ADL care, and respiratory/tracheostomy care. Corrective actions were implemented including staff education, suspension and termination of staff, and policy reviews.

There were 8 complaints and Facility Reported Incidents (FRIs) investigated. Complaint NV00072771 was substantiated. Complaints NV00073174 and FRIs NV00072870, NV00072918, NV00073164, NV00073222 were substantiated with no deficient practice. FRIs NV00072865 and NV00073182 were not substantiated with no regulatory deficiencies identified.

The facility failed to ensure the call light buttons were within reach of one sampled resident, posing potential safety risks. Several complaints and FRIs were substantiated with no deficient practice, while two FRIs were not substantiated. Corrective actions including staff reeducation and call light audits were implemented.

Complaint NV00072771 triggered the investigation. The deficiency was substantiated based on observation, interviews, and record review.

The facility failed to ensure that the call light buttons were within reach of one of eleven sampled residents, posing a potential safety risk of delayed assistance and possible falls or discomfort.

The complaint investigation substantiated that Resident #4 eloped from the facility on 10/22/2024 and was missing for several hours. Staff failed to report the resident missing in a timely manner, and a nurse in training falsely documented that the resident refused a blood glucose check. The facility took corrective actions including termination of the nurse in training and staff education.

The facility failed to ensure adequate supervision of a resident with severe cognitive impairment, resulting in the resident eloping from the facility and being missing for several hours. Staff failed to properly report and locate the resident, and inappropriate documentation was made by a nurse in training. Corrective actions were taken including staff termination, reprimand, and additional training.

The facility was found deficient in maintaining personnel records, specifically failing to ensure that one of ten employee files contained evidence of a Nevada Automated Background System (NABS) clearance, placing residents at risk for inappropriate care.

Complaint #NV00070737 related to pressure ulcer care; Complaint #NV00071740 related to dialysis care and communication.

The facility failed to develop a complete care plan for denture care, provide pressure ulcer preventative measures, ensure 1:1 feeding assistance per physician orders, maintain dialysis appointments and communication records, complete required antipsychotic medication assessments, and maintain safe food storage and sanitation practices. These deficiencies posed risks of malnutrition, worsening pressure ulcers, inadequate dialysis, adverse medication effects, and foodborne illness.

Complaint #NV00070737 involved failure to provide pressure ulcer care for Resident 246. Complaint #NV00071740 involved failure to ensure dialysis appointments were not missed and dialysis communication records were completed for multiple residents (Residents 114, 220, 176, 113, 126).

The facility failed to provide adequate pressure ulcer preventative measures for one resident, including failure to reposition the resident as required. Additionally, the facility failed to ensure dialysis appointments were not missed and dialysis communication records were completed for several residents, resulting in risks for complications such as fluid overload and electrolyte imbalance.

The complaint investigation was substantiated regarding the fall incident inside the facility bus on 09/21/2023 involving Resident 1. The Director of Nursing confirmed the investigation and substantiation. The complaint related to food temperature issues was also documented with multiple resident complaints and grievance logs indicating ongoing issues with cold food.

The facility failed to ensure proper securement of a resident in a wheelchair during transport, leading to a fall and fractures of the resident's right hand. The investigation substantiated the incident and found lapses in staff training and adherence to safety protocols. Additionally, the facility failed to serve food at appropriate temperatures, with multiple residents reporting cold meals, which could affect nutritional intake and resident satisfaction.

The facility was found deficient in maintaining complete personnel records, including missing employee screening reference checks, physical examinations, and Nevada Automated Background System (NABS) clearances for several employees. Additionally, the facility failed to ensure required dementia training was provided to some employees. These deficiencies placed residents at risk for receiving inappropriate care.

The complaint investigation verified neglect by a CNA who failed to properly operate a mechanical lift, resulting in a resident fall and injury. The CNA was terminated but was not reported to the State Board of Nursing as required. The investigation confirmed the incident as neglect.

The facility failed to report a CNA involved in neglect to the State Board of Nursing and did not conduct a required background check. Additionally, the facility failed to update the care plan for a resident involved in a resident-to-resident altercation. These deficiencies had the potential to place residents at risk of harm.

The facility was found deficient in multiple areas including failure to obtain physician orders and assessments for medication self-administration, inadequate safeguarding of protected health information, failure to report verified neglect to the State Board of Nursing, incomplete care plans after resident altercations, improper medication administration and documentation, resident leaving facility without staff awareness, lack of care orders for IV access, unsecured medication carts, expired and unlabeled food items, failure to provide hospice services as ordered, and incomplete mandatory staff training.