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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINTED: 10/24/2011
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
______________________
B. WING _____________________________
(X3) DATE SURVEY
COMPLETED
295037 03/04/2011
NAME OF PROVIDER OR SUPPLIER
HENDERSON HEALTHCARE CENTER
STREET ADDRESS, CITY, STATE, ZIP CODE
1180 E. LAKE MEAD DRIVE
HENDERSON, NV 89015
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
ID
PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
F 241 Continued From page 10 F 241
performing work duties.
5. Resident #4
Resident #4 was a 31 year old female who was
treated at an area hospital from 1/21/2010 -
2/13/2010, for status post anoxic encephalopathy
secondary to drug overdose and status post PEG
(percutaneous endoscopic gastrostomy) tube
placement. Resident #4 was admitted to the
facility on 2/13/2010, with diagnoses including
anoxic brain damage, adult failure to thrive,
anxiety, generalized pain, dysphagia,
hypotension, convulsions, gastrostomy, and
hypoglycemia. Resident #4 moved all extremities
spontaneously, she was unable to follow direction
and was not verbally responsive. Resident #4
was unable to make her needs known. Resident
#4 opened her eyes spontaneously but did not
keep eye contact with verbal stimuli.
On 3/1/2011, in the morning, standing in the
hallway directly outside Resident #4's room, urine
odor was noted coming from her room. Resident
#4 was located on the B side of the room which
was the bed closest to the window. Standing in
the hallway directly outside Resident #4's room,
one could not see Resident #4 due to the privacy
curtain blocking the view. Upon entering the
room, the only way to see Resident #4 was to
enter and go directly to her area in the back of the
room next to the wall. Resident #4's room was
dim due to the window valence being partially
closed. There was no television in the room and
no radio. A black folded wheelchair was beside
the wall in the resident's side of the room.
On 3/1/2011, in the morning, Resident #4 was
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J8O811
Facility ID: NVS263S If continuation sheet Page 11 of 68