The Benjamin Healthcare Center

Inspectors wroteBased on observations and interviews, the facility failed to maintain a homelike environment on two out of three resident units.

Inspectors wroteBased on record review and interview, the facility failed to develop a plan of care for the use of an antipsychotic medication for one Resident (#27) out of a total sample of 20 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for one Resident (#35) out of a total sample of 20 residents. Specifically, for Resident #35, the facility failed to ensure supervision with meals and the use of utensils.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards for one Resident (#15) out of a total sample of 20 residents. Specifically, the facility failed to identify and accurately document a bruise.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary treatment, services, interventions to promote healing and prevent new pressure ulcers from developing for one Resident (#12) out of 20 total sampled residents. Specifically, the facility failed to ensure the Resident's air mattress was set at the correct setting according to the physician's order.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement fall interventions for three Residents (#48, #27, and #28) out of a total sample of 20 residents.1. For Resident #48, the facility failed to ensure his/her bed and chair alarms were in place and functioning.2. For Residents #27 and #28, the facility failed to ensure fall mats were in place.

Inspectors wroteBased on record review and interview, the facility failed to address a significant weight loss and complete a comprehensive assessment after a significant weight loss was identified for one Resident (#20) out of a total sample of 20 residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate medical records for two Residents (#27 and #35) out of a total sample of 20 residents. Specifically;For Resident #27, the facility failed to maintain a complete and accurate medical record with accessible physician's notes. For Resident #35, the facility failed to complete daily documentation for activities of daily living care.

Inspectors wroteBased on observations, records reviewed and interviews, for three of three shower rooms utilized by the residents, the Facility failed to ensure it provided a safe, functional, and sanitary environment, when door locks to the shower rooms did not function properly, shower rooms were not clean, smelled musty, were observed with visible areas of mold, and the overhead ventilation system was nonfunctional.

Inspectors wroteBased on observations, records reviewed, and interviews, for one of three resident units (2-West Unit), which had a resident census of 27, nine of whom were identified to be at risk for elopement, the Facility failed to ensure they maintained a safe and functional environment for residents, staff, and visitors, when the alarm on the stairwell fire door malfunctioned, the alarm was removed, and then a staff member zip tied the fire door closed, preventing the door from opening in case of an emergency for seven days from 06/18/2025 through 06/24/2025. The Facility also failed to ensure that multiple fire doors throughout the facility had functioning alarms, that a fire door self-closed once opened, and that staff monitored malfunctioning alarmed doors for resident safety.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically: 1. The facility failed to ensure frozen foods were maintained frozen. 2. The facility failed to ensure available food was not expired, and that food was dated and securely stored. 3. The facility failed to ensure the dietary staff practiced proper hand hygiene and handled food in a way to minimize possible cross-contamination. 4. The facility failed to ensure the dish machine met proper sanitation requirements when staff used expired test strips and the wrong test strips. 5. [...]

Inspectors wrote2. Resident #28 was admitted to the facility in August 2022 and has diagnoses that include but are not limited to Alzheimer's Disease, and urinary tract infection. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #28 scored a 0 out 15 on the Brief Interview for Mental Status indicating he/she as having severe cognitive impairment. The MDS also indicated Resident #28 was dependent on staff for most aspects of daily care. On 4/28/25 at 8:38 A.M., Resident #28 was observed near the nursing desk in a recliner chair, Resident #28 was observed to be frail and did not respond to the surveyor's greeting. Review of Resident #28's medical record indicated that Resident #28 had a legal guardian. Review of Resident #28's paper medical record under both the care plan tab and social service tab failed to indicate documentation related to interdisciplinary care plan meetings. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of three Residents (#71, #45 and #13) out of a total sample of 24 residents 1. For Resident #71, the facility failed to ensure significant weight loss was assessed and continually monitored. 2. For Resident #45, the facility failed to implement physician's orders for weekly weights, dietary recommendations for fortified foods and the dietitian failed to evaluate significant weight loss following hospitalization. 3. For Resident #15 the facility failed to ensure quarterly nutrition assessments were completed on a resident with a feeding tube. 4. For Resident #13, the facility failed to obtain weights as ordered.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were provided in accordance with standards of nutritional standards to ensure the nutritional needs of residents were met. Specifically, the facility failed to ensure the menu, including the therapeutic breakdown for specialized diets, was provided to the staff serving the daily meals.

Inspectors wrote2. Resident #65 was admitted to the facility in January 2025 with diagnoses that include type 2 diabetes mellitus, dementia and failure to thrive. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #65 was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed his/her to have severe cognitive impairment. The MDS also indicated Resident #65 is dependent on staff for daily care activities including bathing, dressing and eating. Further review of the MDS indicated Resident #65 as being 66 inches in height and weighing 114 pounds and has the nutritional approach of a feeding tube with the percentage of intake by artificial route as 51% or more. During an interview on 4/29/25 at 9:39 A.M., Certified Nursing Assistant (CNA) #3 said Resident #65 used to receive meal trays but he/she no longer eats or takes anything by mouth. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a call light for one Resident (#11) out of a total sample of 24 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#45) out of a total sample of 24 residents. Specifically, for Resident #45, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record.

Inspectors wroteBased on observation, record review and interview, the facility failed accurately complete the Minimum Data Set Assessments (MDS) for three Residents (#45, #82 and #72) out of a total of 24 sampled residents. Specifically, 1. For Resident #45 the facility failed to accurately code the presence of a Stage 4 pressure ulcer. 2. For Resident #72 the facility failed to accurately assess his/her behaviors patterns on the comprehensive MDS. 3. For Resident #82 the facility failed to ensure an accurate discharge MDS assessment was completed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#31 and #16) out of a total sample of 24 Residents. Specifically, 1. For Resident #1 the facility failed to develop an Activities of Daily Living (ADLs) care plan. 2. For Resident #16, the facility failed to implement a care plan for risk of pressure injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure that physician's orders were followed for two Residents (#45 and #184) out of a total sample of 24 residents. Specifically, 1. For Resident #45 the facility failed to complete weekly skin checks as indicated in the physician's orders. 2. For Resident #184, the facility failed to implement physician's orders to apply compression stockings.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with meals for two Residents (#16 and #5) out of a total sample of 24 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure standards of quality of care for two Residents (#22 and #35) out of a total sample of 24 residents. Specifically, 1. For Resident #22 the facility failed to identify a change in his/her skin condition and failed to ensure the weekly skin checks documented the skin change. 2. For Resident #35, the facility failed to a. accurately complete skin checks and b. complete skin checks weekly.

Inspectors wroteBased on observations, record review and interviews, the facility failed to 1. follow the wound recommendations for one Resident (#184) and 2. implement wound treatment for a pressure ulcer for Resident (#60) out of a total sample of 24 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one Resident (#31) out of a total sample of 24 residents, received proper treatment and care in accordance with professional standards, to maintain good foot health and prevent complications form the resident's medical conditions.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that services were provided in accordance with professional standards for one Resident (#65) with a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition) out of 2 applicable residents, out of a total sample of 24 residents. Specifically, Resident #65 was not seen by the Registered Dietician, when Resident #65 was no longer provided meal trays and became NPO (nothing by mouth) and had weight loss. Resident #65 was admitted to the facility in January 2025 with diagnoses that include type 2 diabetes mellitus, dementia and failure to thrive. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure professional standards of practice for two Residents (#59 and #79) requiring respiratory care and treatment, out of a total sample of 24 residents. Specifically, For Residents #59 and #79, the facility failed to clean the oxygen concentrator filter and failed to provide the oxygen as ordered.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to ensure a comprehensive care plan was developed for Trauma Informed Care for one Resident (#78) who had a history of trauma out of a total sample of 24 residents. Specifically, for Resident #78, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings Include: Resident #78 was admitted to the facility in April January 2025 with diagnoses that included Post-Traumatic Stress Disorder (PTSD), major depressive disorder, conversion disorder, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/17/25, indicated that Resident #78 had a Brief Interview for Mental Status (BIMS) exam score of 14 out of 15 indicating he/she is cognitively intact. The MDS further indicated Resident #78 has an active diagnosis of PTSD. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that side rails were implemented in accordance to the Resident assessment for one Resident (#45) out of a total sample of 24 Residents. Findings Include: Review of facility policy titled Informed Consent for Use of Bed Rail(s), undated, indicated the following: -The [facility] will use bed rail(s) only after evaluation and care planning has indicated it is appropriate to treat the resident's medical symptoms and will assist the resident to attain or maintain his/her highest practicable physical and psychosocial well-being, and other considered alternatives are inadequate- The center will endeavor to use the least restrictive device. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis, and anoxic brain injury. [...]

Inspectors wroteBased on records reviewed and interview, the facility 1) failed to ensure one Resident (#71) was free from unnecessary medications by not reassessing a PRN (as needed) psychotropic medication and 2) failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#47) who was receiving antipsychotic medications out of a total sample of 24 Residents.

Inspectors wroteBased on observations and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Specifically, 1. The facility failed to maintain Enhanced Barrier Precautions (EBP) while performing wound care on a resident. 2. For Resident #60, the facility failed to implement EBP for a resident with an open wound. 3. The facility failed to provide documentation of measures to prevent the growth of Legionella (can grow in building water systems, particularly in warm, stagnant water and can cause a severe form of pneumonia -Legionnaires' disease) and other opportunistic waterborne pathogens in building water systems.

Inspectors wroteBased on staff interviews the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services (FSD). Findings Include: During an interview on 5/22/24 at 1:41 P.M., Dietary staff #1 said he was employed as a cook at the facility. Dietary staff #1 said that the FSD had resigned around September of 2023 and that the facility had not hired a replacement. [NAME] #1 said he was delegated responsibilities such as ordering food, scheduling staff, and conducting staff in-services in the absence of a Food Service Director. [NAME] #1 said he had completed a food safety course but did not have a certification for food service management, an associates or higher degree in food service management or hospitality, or two or more years of experience in the position of a Director of Food and Nutrition services in a nursing facility setting. [...]

Inspectors wroteBased on record review and interview the facility failed to conduct CORI (Criminal Offender Record Information) checks for 5 of 5 employee files reviewed, prior to when their employment commenced in the facility.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed and/or implemented for three Residents (#59, #14, and #60) out of a total sample of 19 residents. Specifically, 1. For Resident #59, the facility failed to ensure a resident-centered personalized care plan was developed for a pacemaker. 2. For Resident #14, the facility failed to apply booties per his/her physician's order. 3. For Resident #60, the facility failed to implement the use of built up handled utensils for all meals.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure that acceptable parameters of nutritional status were maintained for one Resident (#30) out a total sample of 19 Residents. Specifically, the facility failed to address a clinically significant weight loss in a timely manner.

Inspectors wroteBased on records reviewed and interviews, the facility which maintained an average daily occupancy of greater than 60 residents (averaging 78 resident per day), failed to ensure the Director of Nurses (DON) did not serve as a charge nurse on a unit.