Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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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 | — | 1 | 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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