ElderGrade

Inspection citations at Hennessey Nursing & Rehab

32 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 7 0
2024 17 2
2023 8 0
D March 26, 2026 Tag F0842 Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D March 26, 2026 Tag F0657 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D March 26, 2026 Tag F0554 Corrected Apr 2026

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E March 26, 2026 Tag F0580 Corrected Apr 2026

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

F March 26, 2026 Tag F0801 Corrected Apr 2026

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

No actual harm, potential for more than minimal harm

F March 26, 2026 Tag F0727 Corrected Apr 2026

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

No actual harm, potential for more than minimal harm

F March 26, 2026 Tag F0577 Corrected Apr 2026

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0880 Corrected Sep 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0758 Corrected Sep 2024

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0730 Corrected Sep 2024

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0695 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0678 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0661 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0656 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0655 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0636 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0623 Corrected Sep 2024

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, potential for more than minimal harm

D August 7, 2024 Tag F0622 Corrected Sep 2024

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

No actual harm, potential for more than minimal harm

E August 7, 2024 Tag F0883 Corrected Sep 2024

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

E August 7, 2024 Tag F0700 Corrected Sep 2024

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

D April 15, 2024 Tag F0755 Complaint investigation Corrected Apr 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D April 15, 2024 Tag F0694 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

G April 15, 2024 Tag F0686 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

J April 15, 2024 Tag F0684 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Immediate jeopardy to resident health or safety

D July 6, 2023 Tag F0880 Corrected Aug 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D July 6, 2023 Tag F0770 Corrected Aug 2023

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

No actual harm, potential for more than minimal harm

D July 6, 2023 Tag F0700 Corrected Aug 2023

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

D July 6, 2023 Tag F0657 Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D July 6, 2023 Tag F0645 Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D July 6, 2023 Tag F0558 Corrected Aug 2023

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E July 6, 2023 Tag F0842 Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

E July 6, 2023 Tag F0644 Corrected Aug 2023

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.