Benson Heights Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of Range of Motion (ROM) for 1 of 5 sampled residents (Resident 4) reviewed for limited ROM. Resident 4 experienced harm as evidenced by after discharge from specialized rehab services the resident was able to open/close their right hand and perform Active ROM (AROM) and now Resident 4's right hand developed a contracture due not implementing therapy gloves, staff not consistently assisting resident with AROM as assessed and care planned. Resident 4 was also at risk for decreased ROM/worsening of left-hand contracture due to staff not implementing rehab training gloves, consistently applying splint, and consistently assisting the resident with Passive ROM (PROM). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Staff H (Dining Services Manager) met the minimum qualifications to serve as the director of food and nutrition services when the facility had no qualified dietitian or other clinically qualified nutrition professional employed full-time. This failure placed residents at risk for unmet nutritional needs and for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 1 sample residents (Resident 15) reviewed for food concerns, and failed to implement a system to ensure residents were provided with the correct food portion sizes according to their assessed nutritional needs for 1 of 1 kitchen tray line observations. These failures placed residents at risk for unmet nutritional needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions for 1 of 1 kitchens and 1 of 1 unit refrigerators designated for resident use. The failure to ensure food was not expired, ensure proper food labeling, and ensure staff performed hand hygiene during food preparation placed residents at risk for foodborne illness and the spread of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided with a homelike environment for resident areas in 2 of 3 units (North & Middle hallways) and the main dining room. These failures put residents at risk for skin injuries and a less-than-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of a written discharge or transfer notice to the Office of the State Long-Term Care Ombudsman (LTCO - resident advocates) for 1 of 3 residents (Resident 89) reviewed for closed records and 2 of 2 supplemental residents (Residents 24 & 95) reviewed for discharge notifications. Failure to notify the LTCO of all resident discharges placed residents at risk of a lack of advocacy in the event of an inappropriate discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and services consistent with professional standards and deliver oxygen therapy according to physician orders (POs) for 1 of 2 residents (Resident 2) and 1 supplemental resident (Resident 60) reviewed for respiratory care. These failures placed residents at risk for potential negative outcomes such as under oxygenation, respiratory discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity for 2 of 4 sampled residents (Residents 91 and 8) reviewed for dignity. The facility staff failed to provide Resident 91 with a privacy bag for their catheter, provide privacy while providing feeding tube care and put abdominal binder to protect feeding tube under their shirt for Resident 8. These failures placed residents at risk for feelings of diminished self-worth and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders (PO's) were followed for 2 of 5 residents (Residents 23 and 43) reviewed for unnecessary medications and 2 supplemental residents (Residents 91 and 11). The failure to follow orders for bowel protocols, to check ordered parameters for blood pressure (BP) medications, and to ensure topical medications were only given with a PO by qualified staff placed residents at risk for inappropriate treatment, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene (HH) during incontinence for 1 supplemental resident (Resident 11) reviewed for incontinence care, and failed to ensure staff used Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measure used to reduce the spread of multidrug-resistant organisms) for 1 of 3 sample residents (Residents 48) reviewed for skin conditions, 1 of 3 sample residents (Resident 71) reviewed for urinary catheters (flexible tube inserted into the bladder to drain urine) and 1 of 1 sample resident (Resident 8) reviewed for tube feeding (surgically implanted tube directly into the stomach to deliver nutrition, fluid and/or medications). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (Resident 1) of 3 residents reviewed received the necessary care and services in accordance with professional standards of practice and the resident's choice. The facility failed to ensure Resident 1 had pain medications available, new staff was aware of facility protocols when a resident requested hospitalization, and failed to honor Resident 1's request to go to the hospital. These failures placed all residents at risk for unmet care needs and left Resident 1 feeling helpless, anxious, and fearful.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food and drinks served to residents were prepared and distributed under sanitary conditions for 1 of 1 facility kitchens. The failure to maintain an effective system for sanitizing counters and monitor refrigerator temperatures placed residents at risk for contaminated/spoiled food, foodborne illness, and other negative health outcomes.

Inspectors wroteBased on record review and interview the facility failed to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 3 residents (Residents 22, 63, & 82) reviewed for hospitalizations and 1 supplemental resident (Resident 20) reviewed. The failure to ensure written transfer notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make an informed decision about the transfer/discharge.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits were provided) for the use of bed rails and/or the bed against a wall for 3 of 6 residents (Residents 63, 4, & 70) reviewed for bed rails/bed against the wall. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options.

Inspectors wroteBased on interview and record review, the facility failed to ensure a level II Preadmission Screening and Resident Review (PASRR- a mental health screening required prior to nursing home admission) evaluation was completed and/or incorporated into the Care Plan (CP) for 4 of 6 residents (Residents 61, 22, 82, & 20) reviewed for PASRR. This failure placed residents at risk for unmet mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 6 of 18 residents (Residents 34, 10, 4, 63, 70 & 38). This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wrote<Resident 34> According to the 11/20/2024 admission MDS, Resident 34 had medically complex diagnoses including a spinal fracture and a history of falling. The MDS showed Resident 34 had frequent pain that affected their sleep and ability to participate in activities and therapy. Record review showed two physician orders for a pain medication patch: a 02/18/2025 physician's order for a pain medication patch to be placed on Resident 34's lower back in the evening and removed at bedtime for pain, and a 02/19/2025 physician's order for the same pain medication patch to be applied in the morning and removed in the afternoon. The orders did not include the strength of the painkiller required. In an interview on 02/25/2025 at 9:32 AM, Staff B (Director of Nursing) stated they expected orders to be clarified when unclear. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement skin breakdown interventions for 1 of 6 residents (Resident 61) reviewed for positioning/mobility and failed to provide weight monitoring for 1 of 1 resident (Resident 82) reviewed for edema. The failure to ensure palm protectors were used as ordered (Resident 61) and weights monitored as required (Resident 82) placed residents at risk for skin breakdown, weight loss, weight gain, and other negative health outcomes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure safety assessments were completed for 3 of 6 residents (Residents 4, 63, & 70) reviewed for bed against the wall/bed rails, failed to store chemicals and razors for 1 of 2 utility rooms (North Utility Room) and failed to supervise the leave of absence for 1 of 2 residents (Resident 90) reviewed for leave from the facility. Failure to complete safety assessments for the beds against the wall, store chemicals and razors safely, and supervise a resident at risk for safety while on a leave of absence placed residents at risk of entrapment and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 5 sampled residents (Residents 38 & 22) reviewed for Oxygen (O2) administration were provided care consistent with professional standards of practice. Failure to provide oxygen monitoring and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, infection, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents consistent with professional standards of practice including the failure to follow parameters for administration of as needed (PRN) pain medications for 1 of 3 residents (Resident 74) reviewed for pain management and monitor for side effects to pain medications for 1 of 5 residents (Resident 22) reviewed for unnecessary medications. These failures placed residents at risk for experiencing untreated pain, possible side effects, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure medically-related social services were provided for 2 of 2 residents (Residents 10 & 21) reviewed for Pressure Ulcers (PU). The failure to provide assistance to residents demonstrating behaviors of rejection of care placed residents at risk for worsening skin and other negative health outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure freedom from unnecessary medications for 1 of 2 residents (Resident 63) reviewed for antibiotic use. The failure to ensure an order for antibiotic therapy was transcribed accurately per physician order resulted in Resident 63 receiving an unnecessary medication for an excessive duration and placed them at risk of experiencing avoidable adverse side effects to the medication and other potential negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents requiring specialized diets were provided the diets required for 1 of 4 residents (Resident 64) reviewed for food. The failure to provide specialized diets residents were assessed to require placed residents at risk for unmet nutritional needs and other negative health outcomes.

Inspectors wrote<Resident 60> According to 10/12/2023 progress note Resident 60 discharged emergently to the hospital. The note showed the facility called 911 after the resident was observed to be lethargic and flushed. A 10/18/2023 provider progress note showed Resident 60 remained in the hospital from [DATE] to 10/18/2023 before returning to the facility. Review of Resident 60's record showed no documentation to demonstrate the LTCO was notified as required. In an interview on 11/16/2023 at 1:12 PM, Staff I stated they were unaware of the ombudsman notification requirements and did not have a system in place to track resident hospitalizations. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide/follow breakout menus for therapeutic diets, follow measurement tool/conversion tables when preparing modified consistency diets. This failure put residents at risk for receiving foods that exacerbated potential life-threatening diagnoses, choking or aspiration (inhaling food contents into lungs), developing lung infections, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that, unless the facility employed a full-time Registered Dietitian (RD), the Director of Food and Nutrition services (Staff N) met Washington State requirements including the completion of an academic program in nutrition or dietetics (the practical application of the science of diet and nutrition in relation to health and/or diseases) approved by the American Dietetic Association/Dietary Manager Association. This failure compromised residents' nutritional status and placed residents at risk for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services management.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow menus, provide menus to residents, or have menus reviewed/approved by a qualified nutrition professional. This failure placed residents at risk of dissatisfaction with meals, residents not being able to have choices, and unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was procured, stored, prepared, and served in accordance with professional standards of safety. The facility failed to ensure: (1) Foods were at a safe temperature before serving to residents, (2) open foods were covered and dated, (3) dietary staff practiced good hygiene and sanitization methods, (4) menu ingredients were ordered and readily available as per menu cycle, (5) meal ticket accuracy to ensure all residents were provided with meals, (6) outside foods undated and not stored properly. These failures placed residents at risk of developing food borne illnesses, ingesting expired foods, not receiving preferred foods, and the potential to not receive a meal.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a required form that outlined the transfer of financial liability from the nursing facility to the Medicare beneficiary) for 2 of 2 residents (Residents 194 & 195) reviewed for liability notices, who remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended. This failure placed the residents at risk for not being fully informed of the cost of continued SNF services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were revised as needed to reflect resident needs for 7 (Residents 72, 21, 41, 29, 22, 38, & 68) reviewed for CPs and failed to ensure residents were given the opportunity to participate in Care Conferences (CCs) for 20 (Residents 60 & 8) of 5 residents reviewed for CCs. These failures left residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 3 of 3 residents (Residents 3, 13, & 41) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.

Inspectors wroteBased on interview and record review the facility failed to implement ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 2 (Residents 54 & 67) of 2 residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 (Staff H, T, & U) dietary employees reviewed for sufficient support and competent kitchen personnel had Food Handler's card. This failure placed residents at risk for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 4 residents (Residents 72, 54, 67, & 21) reviewed who required a therapeutic diet (a specialty diet ordered by a physician or dietician) received the prescribed diet. Failure to ensure residents received their diet as ordered, placed residents at risk for an inappropriate diet and related negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Residents 24, 42 & 49) reviewed for arbitration agreement. The facility failed to ensure the arbitration agreement for 2 of 3 residents (Resident 42 & 49) whose arbitration agreement contracts were reviewed contained language that did not prohibit or discourage the resident and/or their representative from communicating with federal, state, or local officials. These failures placed residents at risk of lacking understanding of the legal document signed, forfeiture of the right to trial, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to obtain and/or offer assistance to residents or their representatives to formulate Advance Directives (AD) for 6 (Resident 72, 29, 54, 68, 56, & 83) of 20 residents reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 20 residents (Residents 3, 13, & 72) whose Minimum Data Set (MDS- an assessment tool) were completed accurately reflected the resident's condition. The MDS did not identify the presence of loose dentures (Resident 3), did not capture the provision of wound care treatment (Resident 13), and did not determine the degree of vision loss (Resident 72). These failures placed residents at risk for not meeting individualized care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed, implemented, resident-specific for 3 (Residents 72, 13, & 41) of 20 sample residents reviewed. Facility failure to develop and/or implement CPs placed residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed and clarified for 4 of 20 residents (Residents 29, 8, 6, & 41) and ensure medications were given within parameters for 2 of 20 residents (Residents 29 & 72) reviewed. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes. <POs Given Outside of Parameters> <Resident 29> Review of Resident 29's 11/15/2023 order summary showed a 10/08/2023 PO for an over-the-counter pain-relieving medication to be administered to Resident 29 every four hours as needed for pain. This summary showed two 10/08/2023 POs for a narcotic pain-relieving medication. [...]

Inspectors wroteBased on onservation, interview, and record review the facility failed to ensure assistance for Activities of Daily Living (ADLs) provided for 3 of 9 residents (Residents 21, 3, & 13) reviewed for ADLs. The failure to provide assistance with dressing (Resident 21 &13) and nail care (Residents 3 &13) left residents at risk for unmet care needs, an undignified appearance, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and provide resident-centered care and services for 4 of 20 residents (Residents 41, 67, 68, & 69) reviewed for quality of care in accordance with the resident's preferences, goals for care, and professional standards of practice. The facility failed to provide treatment and care to address positioning (Resident 41) and failed to identify skin conditions and perform the necessary assessment and monitoring (Residents 67, 68, & 69). These failures placed residents at risk for discomfort, pain, skin breakdown, and contractures from improper positioning, development and worsening of skin issues, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 3 of 6 sample residents (Residents 60, 41, & 69) reviewed for accident hazards. The failure to assess bolstering (established matress boundaries) devices such as wedges (Residents 41 & 69) and the failure to ensure extension cords were not used in resident rooms (Resident 60) placed residents at risk for accidents, injury, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adaptive equipment with meals for 1 of 1 resident (Resident 41) who was assessed to require assistive devices-eating equipment/utensils. Failure to provide and/or set-up the adaptive eating utensils during meals placed the resident at risk for decreased independence with their Activities of Daily Living (ADLs), decline and/or loss of residual functional mobility, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a minimum of 80 square feet (sq ft) of space per resident in resident rooms as required. The failure to provide the required minimum square footage of living space affected residents' (Resident 3 & 26) well-being and life satisfaction, and placed residents at risk for reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for resident to resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach, for Resident 1 who experienced an attempted sexual act by another resident who removed their brief (undergarment) and was found with their pants down on top of Resident 1 by facility staff, and resulted in Resident 1 being transferred to a hospital emergency room (ER) to undergo a sexual abuse examination. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life.