Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benson Heights Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide ordered ROM, splinting, and rehab gloves led to worsening hand contractures for a resident with paralysis and a neurological disorder. Staff and records showed the resident had care plans for PROM to the left side, AROM to the right side, a left-hand splint, and rehab training gloves, but the resident repeatedly reported the gloves and ROM were not provided. CNAs and management acknowledged the splint and ROM tasks were not consistently carried out, and therapy staff noted the resident’s right hand had declined from opening and closing independently to being unable to move at all.
Unqualified Dietary Manager: The facility failed to ensure the Dining Services Manager met the minimum qualifications to serve as the director of food and nutrition services when no full-time qualified RD or other clinically qualified nutrition professional was employed. Staff H was still working toward a CDM credential and had not completed the required food safety and management course of study, while the RD visited monthly and was not aware the manager lacked the required qualifications.
A resident on a pureed diet reported being served mashed potatoes at lunch and dinner instead of menu items like noodles, and a tray line observation showed the resident received mashed potatoes, pureed chicken, and pureed cauliflower instead of the listed chicken alfredo with noodles and cauliflower. Staff stated pureed residents were given the same menu items as others, but the cook also said mashed potatoes were served for pureed diets and that noodles could be pureed but were not. Staff further lacked a detailed break-out menu for portion sizes and used inconsistent scoop sizes during meal service.
Food storage and hand hygiene practices were not maintained in the kitchen and a resident-use refrigerator. Staff left sliced pepperoni, eggs, sandwiches, grapes, sliced meat, and roast beef improperly labeled or expired, and a cook handled food, equipment, and trash with the same gloves before removing them without HH. Staff also rinsed hands briefly without soap and continued food prep, while another aide washed hands without using proper technique.
Damaged resident areas and dining room: The facility failed to maintain a safe, clean, comfortable, and homelike environment in the North and Middle hallways and the main dining room. Observations found broken door panels/kick plates with sharp edges, damaged door frames, a broken hallway baseboard, a broken overhead bed light cover in a resident room, and broken floor tiles in the dining room. Two residents in one room also had TVs set to the same channels, limiting their ability to watch different programs. The MDS confirmed the damaged items needed repair, and the Admin stated the expectation was for a homelike environment.
Failure to notify the LTCO of resident discharges. The facility did not provide evidence that written discharge notices were sent to the LTCO for three residents, including one family-directed discharge home and two resident-driven discharges to adult family homes. Staff stated LTCO notification was not done for resident-initiated discharges, despite facility policy requiring LTCO notice before or as close as possible to transfer or discharge.
A facility failed to provide respiratory care and oxygen therapy according to PO and care plan instructions for two residents. One resident was observed short of breath with the NC not in place and an O2 sat of 86%, while another resident was found in a wheelchair with no tubing connected to the portable O2 tank, using accessory muscles, and with an O2 sat of 53%. Staff did not consistently ensure oxygen was in place, did not document the LPM given for one resident, and did not document physician notification when O2 sats fell below ordered parameters.
Failure to protect dignity during catheter and feeding tube care: one resident with a urinary catheter was repeatedly observed with the drainage bag uncovered and exposed on the wheelchair, while another resident with a feeding tube was observed with an abdominal binder worn over the shirt and received tube medication without privacy. Staff stated catheter bags should be covered, privacy should be provided during tube care, and the binder should be worn under the shirt for dignity.
Failure to follow PO orders affected bowel care, BP med administration, and topical treatments. Two residents with constipation did not receive ordered laxatives, suppositories, or enemas despite multiple days without a BM, and the physician was not documented as being notified. Another resident received a daily BP med without documented SBP or HR checks despite hold parameters, and a CNA applied medicated cream and powder to a resident without a PO for those treatments.
Staff failed to perform HH appropriately during incontinence care for a resident who was fully incontinent and dependent on staff, using the same gloves across dirty and clean tasks before removing them and washing hands only after leaving the room. Staff also did not follow EBP PPE directions for residents with an indwelling urinary catheter, a feeding tube, and chronic wounds: a CNA assisted with dressing without a gown, an RN gave meds via a feeding tube without a gown, and a CNA provided incontinence care without a gown when no EBP signage was posted. Interviews confirmed staff were expected to wear gown and gloves for these residents.
The facility's kitchen failed to maintain sanitary conditions, as observed by the lack of logs for sanitizing solution concentration and refrigerator temperatures. Additionally, improper handling of paper towels and inadequate cleaning practices were noted during lunch preparations, posing a risk of contamination.
The facility failed to provide proper written transfer notifications to residents and their representatives, as evidenced by four cases where forms were either improperly signed or missing. This deficiency involved residents being transferred to hospitals without receiving the necessary documentation to inform them of their rights and appeal procedures.
The facility failed to obtain informed consent for the use of bed rails and bed placement against walls for three residents, despite their medical conditions and care plans indicating the need for such arrangements. Staff E confirmed that consent was not obtained, which is necessary to ensure residents are informed and involved in their care decisions.
The facility failed to complete Level II PASRR evaluations for four residents, including those with severe memory impairment, depression, schizophrenia, PTSD, and significant behavioral issues. Despite indications from Level I screenings, the necessary evaluations were not documented, placing residents at risk for unmet mental health care needs. The Social Services Director acknowledged the oversight and the importance of these evaluations.
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs. A resident on anticonvulsant medication lacked a care plan for its use, while another with a urinary catheter and pressure ulcers did not have individualized Enhanced Barrier Precautions. Three residents had beds against the wall without documentation, and a resident with hearing difficulties lacked a care plan for communication. Additionally, a resident's care plan for seizure medication and antibiotics lacked monitoring details.
The facility failed to obtain and implement physician orders for several residents, leading to potential risks and unmet needs. A resident's bed was placed against the wall without a physician order, and another resident's oxygen tubing was not changed weekly as required. Conflicting orders for a pain medication patch lacked clarity, and a swallow evaluation for a resident at risk of aspiration was delayed. These deficiencies compromised resident safety and care quality.
The facility failed to implement skin breakdown interventions for a resident with severe memory impairment by not using a Therapy Carrot as ordered, and lacked documentation for its application. Additionally, another resident with heart failure and edema was not monitored daily for weight as required, with only weekly checks being conducted, despite the presence of pitting edema.
The facility failed to conduct safety assessments for three residents with beds against the wall, did not secure hazardous materials in an unlocked utility room, and inadequately supervised a resident with a history of PTSD and substance abuse during a leave of absence. The resident left unaccompanied despite a physician order requiring accompaniment, and the care plan lacked necessary interventions.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident with respiratory failure was not monitored according to physician's orders, with low oxygen levels not reported or documented. Another resident's oxygen tubing was not changed weekly as required, increasing infection risk.
The facility failed to provide appropriate pain management for two residents. One resident received incorrect dosages of PRN pain medication, leading to inadequate pain relief. Another resident, on a scheduled pain regimen, was not monitored for side effects despite complaints of sedation. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to prescribed medication parameters and monitoring protocols.
The facility failed to provide necessary social services for two residents with pressure ulcers, leading to a deficiency in care. One resident, with dementia and muscle weakness, refused care, including repositioning, contributing to worsening skin conditions and weight loss. The social services department was unaware of these refusals. Another resident also refused care, and their care plan did not involve social workers, contributing to continued resistance. The DON acknowledged the challenges but did not indicate effective measures to address refusals.
A resident received an antibiotic for 23 days instead of the prescribed 14 days due to a transcription error by the Unit Manager, leading to unnecessary medication administration. The resident, who required a CPAP machine, was at risk of adverse side effects from the prolonged antibiotic use.
A facility failed to provide a resident with the required carbohydrate-controlled, renal diet, despite the resident's complex medical conditions. The Dining Services Director was unaware of the dietary order and struggled to provide the necessary menus, leading to the resident receiving meals that did not meet their nutritional needs. The dietician emphasized the importance of following the correct menus, which were not adhered to by the dietary staff.
Failure to Provide Ordered ROM, Splinting, and Rehab Gloves
Penalty
Summary
The facility failed to provide appropriate treatment, services, and interventions to prevent an avoidable reduction in range of motion for a resident with significant mobility limitations and contractures. Resident 4 had diagnoses including paralysis of the left side of the body, paralysis of the lower half of the body, and a neurological disorder affecting movement, balance, and posture. The resident’s care records included plans for passive ROM to the left hand, arm, and shoulder and active ROM to the right hand, arm, and shoulder, along with a left-hand splint and a functional maintenance program that included rehab training gloves. Observation and interview showed Resident 4’s bilateral hands were contracted closed, and the resident stated staff were not assisting with ROM services and had not provided the rehab training gloves that therapy had placed on the nightstand the prior year. The resident repeatedly stated staff did not offer or provide the gloves, splint, or ROM services. On one observation, the resident was in the day room with both hands contracted and no splint on either hand. A CNA stated the resident was supposed to have a left-hand splint, searched the room, found no splint in the room, and acknowledged the splint and ROM treatments should have been provided. Record review and staff interviews showed therapy had discharged the resident from specialized rehab services with instructions that caregivers continue the rehab training gloves twice daily for 20 minutes, and that caregivers had been trained on their use. Staff later acknowledged the gloves were important to prevent decreased ROM, but they were not added to the care plan or physician orders. Staff also stated the resident should have always worn the left-hand splint and should have received daily ROM, yet CNA documentation reflected misunderstanding about ROM tasks and splints. The OT discharge information and later staff assessment showed the resident’s right hand had worsened from being able to open and close independently at discharge to being unable to move the right hand at all, and staff noted the contractures were worse than when the resident left therapy.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to ensure Staff H, the Dining Services Manager, met the minimum qualifications to serve as the director of food and nutrition services when no qualified dietitian or other clinically qualified nutrition professional was employed full-time. The facility’s policy required that, if a dietitian or qualified nutrition professional was not employed full-time, the director of food and nutrition services be a Certified Dietary Manager (CDM), a certified food service manager, or have similar national certification, or hold an associate’s or higher degree in food service management or hospitality. Staff H stated they had served as the facility’s dietary manager since September 2025, but the staff list showed they were hired on 08/21/2025 and were still working to complete an online course to obtain the CDM credential. Staff H said they started the course in March 2026 and expected to complete it in June or July 2026, while an email showed enrollment in a Dietary Manager Training course beginning 01/14/2026 and ending 01/14/2027. The RD stated they visited monthly, performed kitchen walk-throughs, and held weekly virtual meetings with unit managers, but were not aware Staff H did not meet the minimum qualifications. The Administrator reviewed Staff H’s file and stated Staff H did not currently meet the federal criteria to work as the dietary manager and had not completed the required course of study in food safety and management by 10/01/2023; no documentation was provided showing Staff H qualified for the role.
Menu Not Followed and Portion Sizes Not Standardized
Penalty
Summary
The facility failed to ensure the menu was followed for a resident on a mechanically altered diet and failed to implement a system to ensure residents were provided with the correct food portion sizes according to their assessed nutritional needs. The facility policy stated menus would meet the nutritional and personal needs of residents and would be followed. The cited deficiency was based on observation, interview, and record review involving one resident reviewed for food concerns and one kitchen tray line observation. Resident 15’s 02/24/2026 MDS showed the resident was usually able to understand and be understood, had no natural teeth, and was on a mechanically altered diet. During interview, the resident stated they were on a pureed diet because they did not have teeth and said they were served mashed potatoes for every lunch and dinner, were tired of it, and felt it was too much starch for their nutritional needs. Staff H stated residents on a pureed diet received the same menu items as other residents, and if the menu item was pasta, residents on a pureed diet would receive pureed pasta. The 05/04/2026 lunch menu listed chicken alfredo with noodles and cauliflower, but during tray line observation Resident 15 was served mashed potatoes with sauce, pureed chicken, and pureed cauliflower. Staff J stated they served mashed potatoes for lunch for residents on pureed diets and could puree noodles as indicated on the menu, but did not. Staff I stated residents on a pureed diet should receive the same menu items as other residents and expressed concern that nutritional requirements may not be met if staff did not follow the menu.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions in the kitchen and in a unit refrigerator designated for resident use. During observation with the Dining Services Manager, a large plastic bag of sliced pepperoni was found in kitchen storage with a handwritten date of 09/02/2025 and no other labeling, and three crates of eggs were found with no labeling or expiration date. Later observation showed a kitchen refrigerator containing three undated containers of individually wrapped sandwiches. Staff stated the pepperoni had been pulled from the freezer the previous night, the eggs had been received from the food supplier about two weeks earlier, and the sandwiches had been forgotten during the tray line and were not dated. A unit refrigerator located outdoors on a resident's porch contained two bags of grapes with expiration dates of 04/15/2026 and 04/24/2026, a bag of sliced meat with no open date or expiration date, and a container of sliced roast beef with an expiration date of 05/02/2026. Staff stated the expired or unlabeled items should have been discarded but were not. During food preparation, a cook used gloved hands to handle thawed chicken filets, sauce, the oven door, and the oven temperature dial, then removed gloves without performing hand hygiene. The same cook later returned from outside, rinsed hands for less than five seconds without soap, and continued preparing food with bare hands. Other observations showed the cook and a dietary aide repeatedly washed hands without soap or proper drying, and staff stated hand hygiene should occur when changing gloves, touching dirty items, going outside, smoking, or using the bathroom.
Damaged Resident Areas and Dining Room
Penalty
Summary
The facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment in the North and Middle hallways and the main dining room. Observation showed room [ROOM NUMBER]'s door panel/kick plate was broken with sharp edges, the door frame had dents and scratched-off paint, and another room [ROOM NUMBER]'s door panel/kick plate was broken with a damaged door frame. A separate observation showed room [ROOM NUMBER] had a broken door panel/kick plate and a door frame with dents and chipped paint, and the North hallway wall baseboard was broken. In room [ROOM NUMBER]-Bed 2, the overhead bed light cover was broken, and the resident stated it had been broken for a while. In room [ROOM NUMBER], two residents each had televisions, but both TVs played the same channels, and both residents stated they could not watch the programs they each wanted because the TVs played the same channels. In the main dining room in the South hallway by the kitchen, multiple floor tiles were broken. Staff R, the Maintenance Director, confirmed the damaged door panels, door frames, baseboard, broken overhead bed light cover, and broken floor tiles, and stated they needed to be fixed. Staff A, the Administrator, stated the expectation was for residents to have a home-like environment and that the damaged items should be free from risk of injuries.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to provide a copy of a written discharge or transfer notice to the Office of the State Long-Term Care Ombudsman for 3 residents reviewed for discharge notifications. Facility policy stated that written notification would be provided to the resident and representative before transfer or discharge, that LTCO notification would occur before or as close as possible to the actual time of transfer or discharge, and that the medical record would contain evidence of the notification sent to the LTCO. For Resident 89, a social services note documented that the resident and family member requested discharge home, and an IDT discharge planning and summary showed the resident was discharged home in a family-directed discharge. The EHR contained no evidence that a written discharge notice was provided to the LTCO. Staff D stated the LTCO was not notified because the discharge was initiated by the resident and family, and that monthly LTCO lists were only sent for facility-initiated discharges or transfers. For Resident 24, the IDT discharge planning and summary showed a resident-driven discharge to an adult family home, and the EHR showed no evidence of LTCO notification. For Resident 95, a progress note showed discharge to an adult family home, and the EHR also showed no evidence of LTCO notification. Staff D stated the LTCO was not notified of Residents 24 or 95's discharges.
Failure to Provide Ordered Oxygen Therapy and Respiratory Monitoring
Penalty
Summary
The facility failed to provide respiratory care and oxygen therapy consistent with physician orders and professional standards for two residents. The facility policy stated staff would provide respiratory care in accordance with resident care plans and physician orders, assess and monitor respiratory status, and notify the physician of changes in condition. The deficiency involved Resident 2, who had diagnoses including kidney failure, depression, and dysphonia, and Resident 60, who had medically complex conditions including respiratory problems, memory impairment, altered level of consciousness with behavior fluctuations, and required oxygen therapy. For Resident 2, a physician order directed staff to administer oxygen at 1 to 4 LPM via NC continuously to maintain oxygen saturation above 90% for shortness of breath, and the care plan instructed staff to administer oxygen per order. During observation, Resident 2 was lying in bed with the NC not in place while the oxygen concentrator was on at 2 LPM. The resident stated they felt short of breath and had difficulty breathing. When staff checked the resident, oxygen saturation was 86%, then 87% to 88% after the head of bed was raised, and staff noted the NC was not in the nostrils before placing it there. An RN stated staff should check to make sure the NC was in place, and the DON stated nursing staff were expected to check at least hourly to make sure oxygen was on and in the resident's nose, but they did not. For Resident 60, the care plan instructed staff to keep oxygen settings at 2 to 4 LPM via NC to keep oxygen saturation above 90% and to monitor for shortness of breath, increased breathing, accessory muscle use, and decreased oxygen saturation. During observation, Resident 60 was in a wheelchair in the hallway calling for help, using accessory muscles with forceful chest movement, and stating they were short of breath. A portable oxygen tank on the wheelchair had no tubing connected, and the oxygen saturation was 53%. Staff then connected the NC and placed it in the resident's nostrils, but the saturation remained 53%. The resident was later observed in the hallway without the NC in place, and the saturation was 87%. Review of the MAR showed staff did not document the LPM of oxygen administered as ordered, and progress notes did not document physician notification when oxygen saturation fell below ordered parameters. The DON stated staff were expected to offer oxygen according to the order, document the LPM administered, and notify the physician when saturation fell below parameters.
Failure to Protect Resident Dignity During Catheter and Feeding Tube Care
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity for two sampled residents. One resident admitted with cancer and loss of bladder control had a urinary catheter care plan that included monitoring catheter function and providing catheter care every shift and as needed, but was observed multiple times with the urinary drainage bag uncovered, exposed, and hanging on the wheelchair while in the hallway and in the facility. Staff interviews stated that urinary drainage bags should be covered to ensure resident privacy and dignity. A second resident with some cognitive impairment who required extensive assistance and had a feeding tube was observed with an abdominal binder worn on top of the shirt on multiple occasions. The resident’s nutritional care plan directed staff to place the abdominal binder when the feeding tube was off during the daytime because the resident had pulled at the tube. During one observation, the resident was sitting in the room with the door and privacy curtain open and visible from the hallway while a nurse lifted the resident’s shirt and administered medication through the feeding tube without privacy. The nurse stated the privacy curtain should have been pulled, and the DON stated staff were expected to provide privacy during feeding tube care and that the abdominal binder should be under the shirt for dignity issues.
Failure to Follow Physician Orders for Bowel Care, BP Parameters, and Topical Medications
Penalty
Summary
The facility failed to ensure physician orders were followed for bowel protocols, blood pressure medication parameters, and topical medications. The report identified deficiencies for two residents reviewed for unnecessary medications and two additional residents. The failures involved not carrying out ordered bowel interventions, not checking ordered blood pressure parameters before administering a medication, and allowing topical medications to be applied without a physician order by staff who were not qualified to do so. For one resident with constipation, bowel incontinence, and dependence on staff for toileting hygiene, the care plan directed staff to follow the bowel protocol and keep the physician informed of problems. The physician orders included an oral laxative as needed, another laxative if no bowel movement occurred for three days, a suppository if no bowel movement occurred for four days, and an enema if the suppository was ineffective. Records showed the resident went five days without a bowel movement, but staff did not administer the ordered laxatives, suppository, or enema, and there was no documentation that the physician was notified. A second resident with constipation and impaired lower-extremity mobility had similar bowel protocol orders, and records showed five days without a bowel movement, but staff again did not administer the ordered laxative, suppository, or enema and did not document notifying the physician. For another resident with high BP, the MAR showed a daily BP medication ordered with instructions to hold it if systolic BP was less than 100 or HR was less than 60. The medication was given daily, but the record lacked documentation of systolic BP or HR at the time of administration on multiple days. For a fourth resident with a progressive brain condition, no speech, and dependence on staff for mobility, transfers, and hygiene, a CNA applied a medicated cream and medicated powder during a bed bath even though the resident had no physician orders for those topical medications. Staff interviews confirmed that CNAs were not supposed to apply topical medications and that such treatments required a physician order.
Hand Hygiene and EBP PPE Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene during incontinence care for a resident who was dependent on staff for mobility, transfers, and hygiene and who was always incontinent of bladder and bowel. During one observation, a CNA provided incontinence care while wearing gloves, cleaned the resident’s peri area, and then used the same gloves to apply a clean brief, adjust clothing and linens, operate the bed controller, place a mat on the floor, and move the wheelchair before removing gloves and performing hand hygiene after leaving the room. During another observation, a CNA entered the room, put on gloves without performing hand hygiene, bathed the resident, and then continued care with the same gloves while placing a clean brief, applying medicated cream, powder, and lotion, fastening the brief, dressing the resident, adjusting the bed, and placing a fall mat before removing gloves and leaving without hand hygiene. The facility also failed to ensure staff used PPE in accordance with Enhanced Barrier Precautions for a resident with an indwelling urinary catheter. The resident’s care plan directed staff to wear a gown and gloves during high-contact care activities, including dressing, bathing, transferring, changing linens, changing briefs, assisting with toileting, and catheter care. During observation, a CNA assisted the resident with dressing while wearing gloves but not a gown, despite the EBP sign posted outside the room and the care plan directions. In addition, the facility failed to ensure PPE use for a resident with a feeding tube and for a resident with chronic wounds. For the resident with a feeding tube, the care plan directed staff to wear a gown and gloves during high-contact care and feeding tube care, but a nurse administered medication via the feeding tube without wearing a gown. For the resident with chronic wounds and incontinence, the care plan directed staff to use a gown and gloves for high-contact care, but no EBP signage was posted on the room door and a CNA completed incontinence care without wearing a gown. Staff interviews confirmed they expected gown and glove use for these residents, and the Infection Preventionist and DON stated staff were expected to follow the EBP care plans.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were prepared and distributed under sanitary conditions. During an inspection of the facility kitchen, it was observed that there was no log documenting that the kitchen's sanitizing solution was at an effective concentration. Staff S, the Dining Services Director, was unable to locate the log and confirmed that the sanitizer had not been checked since the shift change over three hours prior. Additionally, the refrigerator logs showed that temperatures had not been recorded for two consecutive days, indicating a lapse in monitoring the refrigeration conditions. Further observations during lunch preparations revealed that the paper towel dispenser was empty, and a roll of paper towels was placed on the counter, with the loose part resting against a can opener. The roll was dotted with drips of water, suggesting improper handling. Staff U, a Dietary Aide, used a piece of paper towel from the roll to wipe down a cart without using sanitizer or washing hands before or after the task, and then returned to food preparation. Staff S acknowledged that the paper towel dispenser should have been refilled and that sanitizer should be used for cleaning surfaces, with gloves only used when handling ready-to-eat foods.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as evidenced by the cases of four residents. Resident 22 was discharged to an acute care hospital without a properly signed transfer notification form, as it only contained the signature of a registered nurse and not the resident's or a witness's signature. The unit manager confirmed that the notification should have been witnessed and provided to the resident or their representative to ensure understanding of their rights. Similarly, Resident 63 was discharged without a properly signed transfer notification form, which only had the staff's signature and not the resident's or representative's. The staff involved believed that the social service staff was responsible for sending the notice to the representative, indicating a lack of clarity in the process. Resident 82's case was further complicated by the absence of a written transfer notification in the health records, with staff unable to locate it in the medical records or scanning bin. The social service director emphasized the importance of providing a written copy to inform residents or representatives about their rights and appeal procedures. Resident 20, who had no memory impairment and a history of medical issues, was transferred to the hospital twice without proper written notifications. Both instances lacked the resident's signature and a witness signature, with only the staff's signature present. The facility administrator stated that nurses were responsible for completing the notification form, while social services were tasked with ensuring the form was provided to the resident or their representative. This deficiency highlights a systemic issue in the facility's process for handling transfer notifications.
Failure to Obtain Informed Consent for Bed Rail and Bed Placement
Penalty
Summary
The facility failed to ensure that residents were provided informed consent for the use of bed rails and the placement of beds against walls, affecting three residents. Resident 63, who had no memory impairment and was diagnosed with general muscle weakness and mobility issues, had a bed rail installed without consent. The care plan indicated the use of an assist rail for bed mobility, but consent was not obtained, as confirmed by Staff E, the Unit Manager. Similarly, Resident 4, who had no memory impairment and was diagnosed with morbid obesity and a history of stroke, had their bed placed against the wall without consent. The care plan did not identify this arrangement, and Staff E acknowledged the oversight. Resident 70, diagnosed with lack of coordination and general muscle weakness, also had their bed placed against the wall without consent, which was not documented in their care plan. Staff E confirmed that consent should have been obtained for these arrangements to ensure residents were informed and involved in their care decisions.
Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASRR) evaluations were completed and incorporated into the care plans for four residents who required them. Resident 61, who was admitted with severe memory impairment and multiple mental health diagnoses, had three Level I PASRR screenings indicating the need for Level II services, but no Level II evaluation was on file. Similarly, Resident 22, diagnosed with depression and schizophrenia, had a Level I PASRR indicating the need for a Level II evaluation, but no such evaluation was documented. Staff D, the Social Services Director, acknowledged the absence of these evaluations and noted the importance of obtaining consultant recommendations for mental health care. Resident 82, with diagnoses including depression and PTSD, also required a Level II PASRR as indicated by a Level I screening, but no documentation of the evaluation was found. Resident 20, who exhibited significant behavioral issues, had a Level I PASRR indicating the need for a Level II evaluation, but this was not completed due to the resident's frequent discharges and admissions. Staff D stated that the hospital should have completed the referral before admission and emphasized the importance of the Level II PASRR in determining the necessary level of care. The lack of completed Level II evaluations for these residents placed them at risk for unmet mental health care needs.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs and negative health outcomes. Resident 34, who had a history of stroke and was on anticonvulsant medication for a seizure disorder, did not have a care plan addressing the use of this medication. The Director of Nursing acknowledged the oversight, noting that a care plan should have been developed to address the anticonvulsant use. Resident 10, diagnosed with difficulty voiding urine and dementia, had a urinary catheter and multiple pressure ulcers. However, the care plan did not reflect the need for Enhanced Barrier Precautions specific to the resident's condition, such as the presence of pressure ulcers and catheter use. The Director of Nursing confirmed that the care plan needed to be individualized to address these specific needs. Residents 4, 63, and 70 had their beds positioned against the wall for safety, but there were no care plans documenting this arrangement. Additionally, Resident 70, who had difficulty hearing, did not have a care plan addressing their hearing impairment. Resident 38's care plan for seizure medication lacked details on monitoring for side effects and drug toxicity, and their antibiotic treatment for respiratory illness was not adequately documented in the care plan. The Unit Manager and Director of Nursing both acknowledged these deficiencies, emphasizing the importance of including medication monitoring in the care plans.
Failure to Obtain and Implement Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained, clarified, and implemented for several residents, leading to potential risks and unmet needs. For Resident 4, the right side of the bed was placed against the wall without a physician order, which was acknowledged by Staff E as necessary to ensure an appropriate plan of care. Similarly, Resident 22's left side of the bed was against the wall without a physician order, and their oxygen tubing was not changed weekly as per facility policy due to the absence of a physician order. Staff F confirmed the importance of having these orders to prevent infection and ensure a physician-guided plan of care. Resident 63 also had their bed placed against the wall without a physician order, which Staff E noted was important for ensuring an appropriate care plan. Resident 71's bed was similarly positioned without a physician order, and Staff E reiterated the need for such an order. Additionally, Resident 34 had conflicting physician orders for a pain medication patch, lacking clarity on the strength of the medication, which Staff B stated should have been clarified. Resident 38, who had a history of stroke and difficulty swallowing, required a swallow evaluation due to the risk of aspiration. Although a physician order for the evaluation was made, it was not completed within the expected timeframe. Staff F and Staff B acknowledged the delay and the need for specific feeding instructions in the care plan, which were pending the evaluation. These deficiencies highlight the facility's failure to adhere to professional standards of practice, potentially compromising resident safety and care quality.
Failure to Implement Skin and Weight Monitoring Interventions
Penalty
Summary
The facility failed to implement skin breakdown interventions for Resident 61, who had severe memory impairment and required total assistance with daily routines. Despite a physician's order to use a Therapy Carrot for hand positioning to prevent skin breakdown, observations on multiple occasions revealed that the Therapy Carrot was not in place. Additionally, there was no documentation available for nursing staff to record the application and duration of the Therapy Carrot use, as confirmed by the Director of Nursing. This lack of documentation and implementation of the ordered intervention placed Resident 61 at risk for skin breakdown. The facility also failed to provide adequate weight monitoring for Resident 82, who had diagnoses of heart failure and edema and was receiving diuretic medication. The care plan required daily weight monitoring to manage edema and prevent complications such as cardiac overload. However, the Unit Manager admitted that Resident 82's weight was only being monitored weekly instead of daily. Observations confirmed the presence of pitting edema in Resident 82's lower extremities, indicating a failure to adhere to the care plan and monitor the resident's condition effectively.
Failure to Conduct Safety Assessments and Supervise Resident Leave
Penalty
Summary
The facility failed to ensure safety assessments were completed for three residents whose beds were placed against the wall. Resident 4, who had no memory impairment and diagnoses including morbid obesity and a history of stroke, did not have a safety assessment completed for their bed's right side against the wall. Similarly, Resident 63, with diagnoses of general muscle weakness and unsteadiness, and Resident 70, with lack of coordination and general muscle weakness, also lacked safety assessments for their beds placed against the wall. Staff interviews confirmed that these assessments were not conducted, which was necessary to ensure resident safety. Additionally, the facility did not secure hazardous materials in the North Utility Room, which was found unlocked with razors, hygiene supplies, and disinfectant cleaners stored in open cabinets. Staff acknowledged that the room should have been locked to prevent resident access to potentially dangerous items. This oversight posed a risk to resident safety, as these materials were accessible to vulnerable individuals. Furthermore, the facility failed to supervise a resident with a history of post-traumatic stress disorder and substance abuse during a leave of absence. Resident 90, who had a physician order requiring accompaniment when leaving the facility, left unaccompanied and admitted to misleading staff about having permission. The care plan did not include interventions for unaccompanied leave, and staff were unaware of the physician's order, which was potentially due to the resident's medical condition requiring a PICC line for antibiotic administration.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 38, who had respiratory failure and low blood oxygen levels, was not monitored according to the physician's orders. Despite orders to monitor blood oxygen levels every shift and notify the provider of low levels, documentation showed that Resident 38's oxygen levels were at or below 90% on multiple occasions without any notification to the provider or adjustments to the care plan. Interviews with staff confirmed that the provider should have been notified, and the low oxygen levels should have been documented in the resident's progress notes. Resident 22, who had respiratory failure and chronic obstructive pulmonary disease, was dependent on supplemental oxygen. The facility's policy required weekly changes of oxygen tubing to prevent respiratory infections. However, observations revealed that Resident 22's oxygen tubing had not been changed according to this policy, as the tubing was dated beyond the weekly change requirement. Staff acknowledged the oversight and the importance of adhering to the policy to prevent infections.
Inadequate Pain Management and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. For one resident with a history of stroke and chronic nerve pain, the facility did not adhere to the prescribed parameters for administering PRN pain medication. On multiple occasions, the resident received incorrect dosages of pain medication, either too high or too low, based on their reported pain levels. This inconsistency in following the physician's orders resulted in the resident experiencing inadequate pain relief, as confirmed by the resident's own report of persistent pain and the staff's acknowledgment of the issue. Another resident, who was on a scheduled pain medication regimen for conditions such as low back pain and arthritis, was not monitored for side effects of the medication. Despite the resident's complaints of excessive sedation and observations of lethargy, there was no physician order to monitor for these side effects. Staff interviews confirmed the lack of monitoring and the importance of ensuring the resident was not experiencing adverse effects from the medication. These failures in pain management practices placed the residents at risk for untreated pain and potential medication side effects.
Failure to Provide Medically-Related Social Services for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide medically-related social services to two residents with pressure ulcers, leading to a deficiency in care. Resident 10, who had conditions such as dementia and muscle weakness, refused care on multiple occasions, including turning and repositioning, which are critical for pressure ulcer management. Despite having a care plan that involved both nurses and social workers to address these behaviors, the social services department was unaware of Resident 10's refusals. This lack of coordination and awareness contributed to the resident's worsening skin condition and significant weight loss. Similarly, Resident 21, who also had dementia and other health issues, refused care and repositioning, which are essential for preventing and managing pressure ulcers. The care plan for Resident 21 did not involve social workers in encouraging participation in care, which may have contributed to the resident's continued resistance to care. The Director of Nursing acknowledged the challenges posed by the residents' refusals but did not indicate any proactive measures taken to address these refusals effectively. The Social Services Director was aware of some behavioral issues but not the specific refusals of care, indicating a gap in communication and intervention strategies.
Antibiotic Administration Error for a Resident
Penalty
Summary
The facility failed to ensure that Resident 63's drug regimen was free from unnecessary medications, specifically concerning the administration of an antibiotic. Resident 63, who had no memory impairment and required a CPAP machine while sleeping, was prescribed a 14-day course of antibiotics for a sinus infection starting on January 15, 2025. However, due to a transcription error, the antibiotic was administered for a total of 23 days, exceeding the physician's order by nine days. The error occurred when Staff E, the Unit Manager, revised the antibiotic order on January 24, 2025, inadvertently restarting the 14-day course. This mistake led to the antibiotic being administered for an excessive duration. Staff C, the Infection Preventionist, confirmed that the antibiotic should have been given for only 14 days. The prolonged administration of the antibiotic placed Resident 63 at risk of experiencing avoidable adverse side effects and other potential negative health outcomes.
Failure to Provide Specialized Diets for Residents
Penalty
Summary
The facility failed to provide specialized diets required by residents, specifically for one resident who was assessed to need a carbohydrate-controlled, renal diet due to complex medical conditions including stage-3 kidney disease, diabetes mellitus, and morbid obesity. Despite the dietary order indicating the need for a specific diet, the resident expressed concerns about the facility not meeting their nutritional needs, citing an example of being served too many carbohydrates at breakfast. This indicates a lack of adherence to dietary requirements, which could lead to unmet nutritional needs and other negative health outcomes for the resident. The Dining Services Director, Staff S, was unable to provide the necessary therapeutic diet menus and was unaware of the resident's dietary order for a renal diet. During meal preparation, it was observed that the dietary staff did not have access to the correct menus, and the instructions provided did not specify the composition of meal trays for different dietary needs. Staff S took 44 minutes to access and print the required menus, and even then, the necessary food items, such as sliced carrots, were not available. The dietician, Staff T, confirmed the importance of following the break-out menus to ensure residents receive the nutrition they require, highlighting a significant lapse in the facility's dietary management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,549 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kent
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Skilled Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 22 | 0 |
| Cedar River Healthcare Center | 3.2 mi | ★★★★★ | 1 | 0 |
| Puget Sound Transitional Care | 4.7 mi | ★★★★★ | 32 | 0 |
| North Auburn Care | 4.9 mi | ★★★★★ | 4 | 0 |
| Wesley Homes Des Moines Health Center | 5.6 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Benson Heights Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.