Inspection Reports for
Henson Park Health & Rehabilitation
203 BRUCE COURT, DANVILLE, KY, 40423
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory standards in multiple areas including resident environment, respiratory care, and food service sanitation.
Findings
The facility was found deficient in maintaining a homelike environment due to damaged ceiling tiles in a resident room, failure to ensure proper respiratory care including undated oxygen tubing and incorrect oxygen flow rates, and unsanitary kitchen conditions including dirty floors, improper sanitizer use, and presence of personal items in food handling areas.
Deficiencies (3)
F 0584: The facility failed to maintain a homelike environment in 1 of 45 resident rooms, with ceiling tiles bulging downward and stained with brown discoloration.
F 0695: The facility failed to ensure supplemental oxygen tubing was dated when changed and that the physician-prescribed oxygen flow rate was followed for 1 of 2 residents reviewed for respiratory care.
F 0812: The facility failed to maintain clean and sanitary kitchen conditions, including dirty floors, improper sanitizer concentration in the three-compartment sink, and presence of personal items in the food handling area.
Report Facts
Resident rooms: 45
Residents reviewed for respiratory care: 2
Residents affected: 1
Residents affected: 1
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding ceiling tile and oxygen tubing issues |
| Maintenance Director | Interviewed regarding maintenance work orders and TELS system | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding staff training and expectations for room safety and oxygen care |
| Administrator | Administrator | Interviewed regarding expectations for room maintenance and oxygen care |
| Intern Dietary Manager | Intern Dietary Manager | Interviewed regarding kitchen sanitation and sanitizer testing |
| Dietary Aide #2 | Dietary Aide | Interviewed regarding sanitizer testing |
| Dietary Aide #3 | Dietary Aide | Interviewed regarding sanitizer testing |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, staffing, medication storage, food sanitation, and infection control at Henson Park Health & Rehabilitation.
Findings
The facility was found to have multiple deficiencies including unsafe and unsanitary environmental conditions such as missing floor tiles and persistent urine odors, failure to provide required RN coverage on certain days, improper medication refrigerator storage, unsanitary food handling practices, and lapses in infection control related to improper sharps disposal.
Deficiencies (5)
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment in four resident rooms, including missing floor tiles and persistent strong urine odors despite repeated cleaning efforts.
F 0727: The facility failed to provide eight consecutive hours of Registered Nurse coverage on four days between 03/01/2024 and 06/12/2024.
F 0761: The medication storage refrigerator on A Hall was unplugged and registered 62°F, exceeding the acceptable temperature range, risking medication efficacy.
F 0812: The facility failed to follow professional food sanitation standards by storing an ice scoop uncovered and towel drying plate covers instead of air drying them.
F 0880: A nurse administered insulin injections but failed to immediately dispose of used syringes and needles, placing them uncovered on a resident's bed, risking infection transmission.
Report Facts
Days without RN coverage: 4
Medication refrigerator temperature: 62
Resident rooms with environment issues: 4
Resident blood sugar: 369
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN6 | Licensed Practical Nurse | Named in infection control deficiency for improper disposal of syringes and needles. |
| RN2 | Registered Nurse | Interviewed regarding missing floor tiles and resident safety. |
| Housekeeper 1 | Interviewed about cleaning efforts and persistent urine odors. | |
| Dietary Aide 1 | Interviewed about towel drying plate covers. | |
| Dietary Director | Interviewed about ice scoop storage and food sanitation. | |
| Administrator | Interviewed about overall facility conditions and corrective actions. | |
| Director of Nursing | Interviewed about staffing, medication storage, and infection control. | |
| Assistant Director of Nursing | Interviewed about staffing and infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding improper medication administration practices by nursing staff.
Complaint Details
The complaint investigation found that three of twenty-three sampled residents were affected by improper medication dispensing practices. The issue was substantiated based on observations and interviews with nursing staff and administration.
Findings
The facility failed to ensure nursing staff adhered to accepted standards for medication administration, specifically dispensing medications from blister packs into ungloved hands before placing them into medication cups. Observations and interviews confirmed this deficient practice among multiple staff members.
Deficiencies (1)
F 0658: The facility failed to provide medication administration services that met professional standards. Staff dispensed medications from blister packs into ungloved hands before placing them into medication cups, contrary to facility policy and accepted practice.
Report Facts
Residents sampled: 23
Residents affected: 3
Medications dispensed improperly: 5
Additional medications dispensed improperly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed dispensing medication from blister packs into ungloved hands |
| RN #3 | Registered Nurse | Observed dispensing medication from blister packs into ungloved hands |
| KMA #3 | Kentucky Medication Aide | Observed dispensing medication from blister packs into ungloved hands and administering to resident |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations and corrective actions for medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding expectations and corrective actions for medication administration |
| Administrator | Administrator | Interviewed regarding investigation and corrective actions for deficient medication practices |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 21, 2023
Visit Reason
The investigation was triggered by a complaint alleging abuse of Resident #9 by CNA #35, including physical abuse and failure to protect the resident from further harm.
Complaint Details
Complaint investigation of abuse allegation involving CNA #35 pushing Resident #9 on 10/12/2023. Immediate Jeopardy was identified and removed after corrective actions including suspension of CNA #35, staff education, and enhanced QAPI oversight.
Findings
The facility failed to protect Resident #9 from abuse by CNA #35, failed to immediately remove the alleged perpetrator, and did not thoroughly investigate or involve the QAPI committee timely. The facility also failed to ensure confidentiality of residents' medical records and failed to follow professional standards in medication administration and medication/treatment cart security.
Deficiencies (6)
F0583: The facility failed to ensure the security and confidentiality of residents' medical records on unattended medication carts, exposing PHI to unauthorized viewing.
F0600: The facility failed to protect Resident #9 from physical abuse by CNA #35, who pushed the resident and used inappropriate language, resulting in immediate jeopardy.
F0607: The facility failed to develop and implement effective policies and procedures to prevent abuse and failed to coordinate abuse prevention with the QAPI program.
F0658: The facility failed to ensure medication administration adhered to accepted standards, as nurses and KMAs dispensed medications from blister packs into ungloved hands.
F0761: The facility failed to ensure drugs and biologicals were stored safely and securely, as treatment carts were found unlocked with accessible creams and ointments posing risk to residents.
F0835: The facility failed to use its resources effectively and efficiently to protect residents from abuse, failed to thoroughly investigate abuse allegations, and failed to involve the QAPI committee timely.
Report Facts
Residents interviewed: 16
Skin assessments: 61
Medications dispensed observed: 4
Tubes of creams/ointments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #33 | Certified Nursing Assistant | Witnessed abuse incident involving CNA #35 and Resident #9. |
| CNA #35 | Certified Nursing Assistant | Alleged perpetrator of abuse against Resident #9, suspended and terminated. |
| LPN #13 | Licensed Practical Nurse | Received report of abuse, instructed to send CNA #35 home, failed to document skin assessment. |
| LPN #3 | Licensed Practical Nurse | Observed dispensing medication from blister packs into ungloved hands. |
| RN #3 | Registered Nurse | Observed dispensing medication from blister packs into ungloved hands. |
| KMA #3 | Kentucky Medication Aide | Observed dispensing medication from blister packs into ungloved hands. |
| DON | Director of Nursing | Responsible for abuse investigation, staff education, and oversight. |
| Administrator #2 | Administrator | Responsible for facility operations and abuse oversight. |
| CNO | Chief Nursing Officer | Provided policy updates and staff training on abuse prevention. |
Inspection Report
Immediate Jeopardy
Deficiencies: 12
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to multiple serious deficiencies including abuse allegations, medication errors, failure to follow care plans, and inadequate supervision resulting in immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation revealed substantiated abuse of Resident #9 by CNA #35 on 10/12/2023. The facility failed to immediately remove the alleged perpetrator, failed to protect the resident from further harm, and failed to conduct a thorough investigation. The QAPI committee did not address the abuse incident timely. The facility implemented an Immediate Jeopardy Removal Plan and staff reeducation.
Findings
The facility failed to protect residents from abuse, ensure accurate medication administration, implement comprehensive care plans, provide adequate supervision to prevent accidents, and maintain secure medication storage. Immediate jeopardy was identified related to abuse of Resident #9, medication errors for Resident #10, inadequate supervision leading to elopement and falls for Residents #9, #14, and #15, and failure to update care plans and code status for Residents #10 and #14. The facility also failed to ensure staff followed policies and procedures, and the Quality Assurance Performance Improvement (QAPI) program did not adequately address these issues.
Deficiencies (12)
F578: The facility failed to ensure Resident #10's code status was updated to Do Not Resuscitate (DNR) on 08/10/2022, resulting in the resident being transferred to the hospital as Full Code and intubated against his/her wishes.
F583: The facility failed to ensure confidentiality of residents' medical records when unattended medication carts had open computers displaying resident information visible to others.
F600: The facility failed to protect Resident #9 from abuse when CNA #35 pushed the resident and was not immediately removed, and failed to conduct a thorough investigation or involve QAPI timely.
F604: The facility failed to ensure Resident #13 was free from physical restraints as the resident was tied to a chair with a gait belt without a physician's order or proper care plan.
F656: The facility failed to develop and implement comprehensive care plans for Residents #4, #9, #13, and #15, including failure to monitor stroke symptoms, implement 1:1 supervision for elopement risk, and provide two-person assist for bed mobility.
F657: The facility failed to review and revise Resident #10 and Resident #14's comprehensive care plans to reflect changes in condition and needs, including failure to update Resident #10's code status and Resident #14's impulsive behavior requiring increased supervision.
F658: The facility failed to provide medication administration according to accepted standards when nurses and KMAs dispensed medications from blister packs into ungloved hands before placing them into medication cups.
F684: The facility failed to identify and provide needed care and services for Residents #4 and #10, including failure to promptly assess Resident #4 for stroke symptoms and failure to administer prescribed pain and antibiotic medications to Resident #10, resulting in harm and death.
F689: The facility failed to provide adequate supervision to prevent accidents for Residents #9, #14, and #15, resulting in elopement, falls, and fractures.
F760: The facility failed to ensure Resident #10 was free from significant medication errors when incorrect medication orders were transcribed and administered, and IV antibiotics were delayed, contributing to sepsis and death.
F761: The facility failed to store drugs and biologicals safely and securely when the C Hall treatment cart was unlocked with various creams and ointments accessible to residents.
F835: The facility failed to use its resources effectively and efficiently to protect residents from abuse, failed to investigate abuse allegations thoroughly, and failed to involve the QAPI program in abuse incident management.
Report Facts
Deficiencies cited: 12
Residents sampled: 25
Residents interviewed: 16
Medication doses missed: 3
Elopement risk score: 16
BIMS scores: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #35 | Certified Nursing Assistant | Alleged perpetrator who pushed Resident #9 and was terminated. |
| LPN #13 | Licensed Practical Nurse | Involved in abuse incident response and documentation. |
| DON | Director of Nursing | Responsible for overall nursing management and abuse incident response. |
| Administrator | Facility Administrator | Responsible for facility operations and abuse incident oversight. |
| MDS Nurse #1 | Minimum Data Set Nurse | Scanned EMS DNR form and involved in care plan updates. |
| RN #4 | Registered Nurse | Discovered medication errors for Resident #10 and communicated with family. |
| Medical Director | Medical Director | Expected facility to follow care plans and be notified of medication issues. |
| CNA #33 | Certified Nursing Assistant | Witnessed abuse incident involving Resident #9. |
Inspection Report
Deficiencies: 1
Date: Apr 18, 2019
Visit Reason
The inspection was conducted to assess compliance with medication labeling and storage regulations in the facility.
Findings
The facility failed to ensure that medications and biologicals were labeled according to accepted professional principles, specifically one medication on a medication cart was opened and not labeled with the open date. Interviews with staff confirmed the importance of dating opened medications to ensure proper treatment and medication efficacy.
Deficiencies (1)
F 0761: The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles. One medication on a Unit B medication cart was opened and not labeled with the open date.
Report Facts
Residents Affected: 4
Date of survey completed: Apr 18, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Responsible for administering medications and medication cart; interviewed about medication labeling | |
| Unit Coordinator | Interviewed about medication cart checks and staff training | |
| Pharmacist | Interviewed about medication labeling and expiration | |
| Director of Nursing (DON) | Interviewed about nursing staff responsibilities for medication labeling | |
| Administrator | Interviewed about staff expectations for medication labeling and storage |
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