Henderson, TX

Henderson Health & Rehabilitation Center

2-star overall rating with 2-star inspections with abuse icon flag with $15,935 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1010 W Main St, Henderson, TX

(903) 657-6513

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

173

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Advanced Healthcare Solutions

Operator or chain grouping

Approved since

1992-01-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

30 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.38

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.85

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.23

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.38

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.03

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.46

CMS adjusted RN staffing hours

Adjusted total hours

3.89

CMS adjusted total nurse staffing hours

Case-mix index

1.13

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,760

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.70

Composite VBP score used to determine payment impact.

Payment multiplier

0.9918

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.60

Baseline 20.96% · Performance 21.15% · Measure score 0.60 · Achievement 0.60 · Improvement 0

Healthcare-associated infections

Baseline 8.02% · Performance 8.26% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.74

Baseline 82.43% · Performance 35.00% · Measure score 7.74 · Achievement 7.02 · Improvement 7.74

Adjusted total nurse staffing

7.15

Baseline 3.93 hours · Performance 5.11 hours · Measure score 7.15 · Achievement 7.15 · Improvement 5.88

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.39%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 49 · Observed rate 14.29% · Lower 95% interval 7.84%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 42 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	54.84%	53.69% 1.2 pts better	Numerator 17 · Denominator 31
Discharge mobility score	61.29%	50.94% 10.4 pts better	Numerator 19 · Denominator 31
Pressure ulcers or injuries, new or worsened	2.38%	2.29% 0.1 pts worse	Numerator 1 · Denominator 42 · Adjusted rate 2.16%
Healthcare-associated infections requiring hospitalization	8.26%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 32 · Observed rate 12.5% · Lower 95% interval 4.41%
Staff COVID-19 vaccination coverage	2.13%	8.2% 6.1 pts worse	Numerator 2 · Denominator 94
Staff flu vaccination coverage	86.21%	42% 44.2 pts better	Numerator 75 · Denominator 87
Discharge function score	61.29%	56.45% 4.8 pts better	Numerator 19 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	2.1 0.5 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.2	2.1 1.1 pts worse	1.8 1.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.6%	3.3% 1.3 pts worse	3.3% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.6% · Q3 5.6% · Q4 4.6% · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	2.7% 1.2 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight	1.4%	3.3% 1.9 pts better	5.4% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.9%	18.9% 1 pts worse	19.6% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 15.3% · Q3 20.3% · Q4 20.0% · 4Q avg 19.9%
Percentage of long-stay residents who received an antipsychotic medication	11.0%	10.8% 0.2 pts worse	16.7% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 8.9% · Q3 14.6% · Q4 5.6% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.8%	15.4% 0.6 pts better	16.3% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 31.6% · Q3 14.3% · Q4 8.1% · 4Q avg 14.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.7%	16.1% 1.6 pts worse	14.9% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 21.4% · Q3 18.5% · Q4 13.7% · 4Q avg 17.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.5% 0.1 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	0.8% 0.1 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.6% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	9.8%	15.0% 5.2 pts better	19.8% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 11.3% · Q3 11.8% · Q4 12.7% · 4Q avg 9.8%
Percentage of long-stay residents with pressure ulcers	2.3%	4.2% 1.9 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.5% · Q3 3.1% · Q4 1.5% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	7.5%	12.0% 4.5 pts better	12.0% 4.5 pts better	Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.7% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 4.5% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.2%	25.9% 3.3 pts worse	23.9% 5.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 25.6% · Expected 20.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-14 · Fire 2025-05-14

10 health deficiencies

Top issue: Infection Control (2 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-04-17 · Fire 2024-04-17

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2023-03-03 · Fire 2023-03-03

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2025-05-14

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

D · Potential for more than minimal harm 2024-04-17

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-05-17

C · Minimal harm 2024-04-17

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

E · Potential for more than minimal harm 2023-03-03

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-04-24

C · Minimal harm 2023-03-03

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

G · Actual harm 2025-09-17

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-10-10

F · Potential for more than minimal harm 2025-05-14

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-06-14

E · Potential for more than minimal harm 2025-05-14

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2025-06-14

D · Potential for more than minimal harm 2025-05-14

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-14

D · Potential for more than minimal harm 2025-05-14

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-06-14

D · Potential for more than minimal harm 2025-05-14

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-06-14

D · Potential for more than minimal harm 2025-05-14

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-06-10

D · Potential for more than minimal harm 2025-05-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-14

E · Potential for more than minimal harm 2025-03-25

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-03-25

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-30

E · Potential for more than minimal harm 2024-04-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-17

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-05-15

L · Immediate jeopardy 2023-03-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-04-04

K · Immediate jeopardy 2023-03-03

F580 · Resident Rights Deficiencies

Health

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

Corrected 2023-04-04

K · Immediate jeopardy 2023-03-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-04

E · Potential for more than minimal harm 2023-03-03

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-04-04