Benton Rehabilitation and Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse to the Illinois Department of Public Health within the required time frame for 1 (R1) of 3 residents reviewed for reporting abuse allegations in a sample of 8.

Inspectors wroteThe facility failed to timely initiate and thoroughly investigate an allegation of staff to resident abuse for 1 (R1) of 3 residents reviewed for abuse in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders were obtained prior to performing pulmonary function tests (PFT) for 4 of 4 residents (R11, R13, R15, R16) reviewed for physician orders in the sample of 17. Findings Include:1. R11's admission Record with a print date of 9/29/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, heart failure, and chronic obstructive pulmonary disease. R11's MDS (Minimum Data Set) dated 8/23/25 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R11 is cognitively intact. R11's current Care Plan documents a Focus Area of Respiratory: DX (diagnosis) COPD, Respiratory failure .Date Initiated: 09/17/2024. This Focus area includes interventions of, Bipap as ordered Date Initiated: [...]

Inspectors wroteBased on interview, observation and record review the facility failed to provide the correct portion size of meat for altered textured diets for 9 (R1, R7, R12, R15, R16, R17, R25, R27, and R35) of 12 residents reviewed for altered textured diets in a sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents during meals to promote dignity for 2 of 12 residents (R1, R15) reviewed for dining in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to notify the physician and the resident's responsible party of a change of condition for 1 of 2 residents (R35) reviewed for notification of changes in the sample of 32.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that a resident's dresser was in a state of good repair for 1 of 1 resident (R31) reviewed for environment in the sample of 32 .

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure a resident's AIMS (Abnormal Involuntary Movement Scale) Assessment was accurately completed for 1 of 1 resident (R20) reviewed for accuracy of assessments in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision to a resident experiencing seizures and implement effective interventions to prevent falls for 1 of 1 resident (R33) reviewed for falls in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to date and secure oxygen tubing and a humidification bottle for one of one resident (R4) reviewed for oxygen in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer and provide dental services for one of one resident (R28) reviewed for dental services in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to administer vaccinations resident previously had consented for, for 2 residents of 5 residents (R29 and R35) reviewed for immunizations in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 resident (R10, R12, R27 and R30) reviewed for room size in a sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the shower room on the South Hall in a clean and sanitary condition. This has the potential to affect 23 residents residing on the South Hall.

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of resident trust funds and private checking accounts from V3, former Business Office Manager for 50 of 50 residents (R1-R50) reviewed for theft in a sample of 52. This failure resulted in checks written for cash on R1 through R50's pooled resident trust account, totaling $5515.19 and checks written from R1's individual checking account totaling $10,650. These actions would cause a reasonable person to have feelings of sadness, worry, stress and anguish while residing in a home where monetary theft occurred. The Immediate Jeopardy began on 12/21/23 when V3 wrote a $250 check for cash on R1's personal checking account, with no documentation as to what happened to the money. V11, Regional Director of Clinical Operations, was notified of the Immediate Jeopardy on 8/13/24 at 3:28pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage, safeguard, and accurately account for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24.

Inspectors wroteBased on interview and record review, the facility failed to perform a pre-employment background checks on the business office manager. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/22/21 to 6/10/24.

Inspectors wroteBased on interview and record review, facility staff failed to immediately report to the Administrator an allegation of potential staff to resident misappropriation of funds. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/1/24 to 6/10/24.

Inspectors wroteBased on interview and record review, the facility failed to begin an immediate investigation into an allegation of staff to resident misappropriation. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 5/23/24 to 6/10/24.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours per day/ 7 days a week. This failure has the potential to affect all 30 residents residing in this facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the infection control program was followed using current standards of practice and per the facility policy for 7 of 8 (R6, R12, R13, R22, R24, R26, and R29) residents reviewed for infection control in the sample of 28. Findings Include: 1. On 04/08/24 at 12:50 PM, PPE (personal protective equipment) containers were noted sitting outside R2, R21, and R23's doors. There was no signage on these doors to indicate the type of transmission-based precautions these residents were on. V2 (DON/Director of Nurses) and V3 (Regional Consultant) stated there were no transmission-based precaution signs on those doors and they didn't know why the residents were on isolation precautions, or if they were. [...]

Inspectors wroteBased on Interview and Record Review, the facility failed to provide Advanced Beneficiary Notice of Non-Coverage (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage/ SNFABN-CMS10055) for 2 of 3 residents (R2 and R26) reviewed for Beneficiary Protection Notification in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to obtain the Pre-admission Screening and Resident Review (PASRR) document for 1 of 5 resident (R29) reviewed for PASRR screening in a sample of 28.

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement interventions to prevent and treat a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers in a sample of 28.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide physician ordered nutritional supplements to 2 of 5 (R1 and R4) residents reviewed for nutrition in a sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure placement was checked to enteral feeding prior to administering flush and feeding for 1 of 1 resident (R29) reviewed for enteral feedings in a sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a menu that met residents nutritional needs for 1 of 1 (R16) residents reviewed for nutrition in the sample of 28. Findings Include: R16's Profile Face Sheet dated 8/3/23 documents R16 was admitted to the facility on [DATE]. R16's Cumulative Diagnosis Log documents diagnoses that include vitamin B and D deficiencies, atrial fibrillation, Alzheimer's disease, and congestive heart failure. R16's MDS (Minimum Data Set) dated 2/6/24 documents a BIMS (Brief Interview for Mental Status) score of 07, which indicates R16 has a moderate cognitive deficit. R16's Physician's Orders sheet dated 4/1/24 to 4/30/24 documents a diet order of Regular, Vegetarian. R16's Nutritional assessment dated [DATE] documents R16 is on a Regular, Vegetarian diet and documents R16's protein needs as 86 gm/day (grams/day). [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide the diet as ordered for 1 (R25) of 5 residents reviewed for nutrition in a sample of 28. R25's Face sheet documents R25 is a male resident with a date of birth of [DATE] and an admission date of 08/16/23. R25's diagnosis in part: Hemiplegia following unspecified cerebvascular disease affecting right dominated, Essential hypertension, End stage renal disease, Hyperlipidemia, Type 2 diabetes with diabetic peripheral angiopathy, Unspecified sequelae of cerebral infarction, Unspecified systolic heart failure, Gastro-esophageal reflux disease without esophagitis, Peripheral vascular disease, Cerebral infarction, reduced mobility, Dysphagia, Muscle wasting and atrophy. R25's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R25 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 5 of 5 residents (R1, R16, R22, R26, R27) reviewed for room size in a sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions and follow facility policies to prevent falls for three of three residents (R1, R2, and R3) reviewed for falls in the sample of 3. These failures resulted in R1 having injuries including a dislocated shoulder and an intertrochanteric fracture of the right femur. The findings Include: 1. R1's Face Sheet documents an admission date of 8/16/23 with diagnoses including: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the state survey agency for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication cart and enclosed narcotic box were kept locked and the keys remained with the nurse passing medications. This has the ability to affect all 30 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a Director of Nursing for the facility and failed to have a Registered Nurse working 8 hours a day/7 day a week. This failure has the potential to affect all 29 residents residing in the facility. Findings Include: On 05/23/23 at 10:20 AM, V1 (Administrator) stated the facility currently does not have a Director of Nursing (DON) and has not since May 2023. V1 states the facility has sought to hire a DON and has had a couple interviews. V1 verified the accuracy of nursing schedules provided and stated the facility does not have any nursing waivers. V1 stated that V9 (Registered Nurse/RN) is the RN that works Monday-Friday, but she was injured on May 9, 2023 and has not yet returned. The May 2023 schedule documents that there was no RN coverage on 5/9/23-5/11/23, 5/15/23-5/18/23 and 5/22/23-5/25/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free from urine odors on the South Hall. This has the potential to affect all 15 residents (R2, R3, R4, R5, R7, R8, R11, R12, R13, R14, R15, R16, R21, R23, and R283) living on the South Hall. The Findings Include: On 5/23/23 at 8:30am, a strong odor of stagnant urine was noted on the South Hall. The odor was noted from room XX to the nurse's station, which is located at the end of the South Hall. On 5/23/23 at 10:58am, R2 was alert only to herself. R2 smelled of body odor and urine. On 5/23/23 at 12:30pm, the urine odor on South Hall was still prevalent. On 05/24/23 at 7:50am, a strong odor of urine was again noted on the South Hall from room XX to the nurse's station. [...]

Inspectors wroteBased on observation and record review, the facility failed to provide dependent residents with twice weekly showers for four residents of five residents (R1, R2, R10, R18) reviewed for ADL's (Activities of Daily Living) in the sample of 29.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a resident's Physician's orders and POLST (Practitioner Orders for Life Sustaining Treatment) Forms match for 1 of 5 residents (R10) reviewed for Advance Directives in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to notify resident's representative in writing of hospital transfers for 2 of 2 residents (R10, R18) reviewed for hospitalizations in a sample of 29. Findings Include: 1. R18's Profile Face Sheet note that R18 was admitted to the facility on [DATE]. Profile Face Sheet list some of R18's diagnoses as unspecified protein-calorie malnutrition, acute kidney failure with tubular necrosis, type 2 diabetes mellitus with diabetic polyneuropathy. R18's MDS (Minimum Data Set) dated 4/30/23 note that R18 has a BIMS (Brief Interview of Mental Status) of 13 which indicates R18 is cognitively intact. Nurse's Note dated 4/29/23 document that R18 was sent to local emergency room after experiencing a fall and complaining of pain in her tailbone. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify by mail the resident or resident's representative in writing of the notification of the facility bed hold policy for 2 of 2 residents (R10, R18) reviewed for hospitalizations in a sample of 29. Findings Include: 1. R18's Profile Face Sheet note that R18 was admitted to the facility on [DATE]. Profile Face Sheet list some of R18's diagnoses as unspecified protein-calorie malnutrition, acute kidney failure with tubular necrosis, type 2 diabetes mellitus with diabetic polyneuropathy. R18's MDS (Minimum Data Set) dated 4/30/23 note that R18 has a BIMS (Brief Interview of Mental Status) of 13 which indicates R18 is cognitively intact. Nurse's Note dated 4/29/23 document that R18 was sent to local emergency room after experiencing a fall and complaining of pain in her tailbone. [...]

Inspectors wroteBased on interview and record review, the facility failed to add new fall prevention interventions for a resident at high risk for falls for 1 of 4 residents (R2) reviewed for falls in the sample of 29.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident was free from unnecessary psychotropic medications by not implement non-pharmacological interventions and behavior monitoring for 1 (R28) of 5 residents reviewed for unnecessary medication in a sample of 29.

Inspectors wroteBased on interview and observation, the facility failed to maintain call lights in working order for 1 of 3 residents (R1) reviewed for functioning call lights in the sample of 29.

Inspectors wroteBased on interviews, observation, and record review the facility failed to provide at least 80 square feet of living space per resident bed for 11 of 11 residents (R1, R2, R6, R8, R10, R11, R14, R15, R20, R23, and R333) reviewed for room size in a sample of 29.