Ben Hur Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ben Hur Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 13, 2021

  A. Based on observation, interview, and record review, the facility failed to ensure a resident was transported appropriately by staff resulting in harm when a resident obtained a spiral fracture of the lateral malleolus when transfered down a ramp in a shower chair without foot pedals for 1 of 1 residents reviewed for accidents (Resident 58). B. Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were maintained within a safe range for 4 of 13 residents reviewed for hot water temperatures (Residents 15, 56, 14, and 49). Findings include: A. During an interview, on 7/6/21 at 2:10 p.m., Resident 58 indicated she was being pushed by staff in her chair, down the facility ramp, when her foot went under the chair, and she broke her ankle. […]

• No harm, potential for more than minimal, patternF812Dec 4, 2023

  Based on observation, interview, and record review, the facility failed to ensure food thermometers were cleaned according to policy which had the potential to effect 9 of 9 residents who received a modified meal from the kitchen. Findings included: During a random kitchen observation on 11/30/23 at 11:40 a.m., food temperatures were checked by Dietary Cook 9. Cook 9 removed a packet from the box, removed the wipe from the packet, cleaned the thermometer, and plunged it into a full container of the soft and bite pizza (modified meal for residents requiring soft and bite size food). The box she retrieved the packet from was observed to be Sureprep Skin Protectant Wipes (a liquid film-forming dressing applied to skin to form a protective barrier to reduce friction). […]

• No harm, potential for more than minimal, patternF657Sep 1, 2022

  Based on interview and record review, the facility failed to ensure a resident was invited to their care plan meeting (Resident 60) and care plans were developed (Residents 2, 52, and 14) for 4 of 21 residents reviewed for care planning. Findings include: 1. During an interview, on 8/25/22 at 2:19 p.m., Resident 60 indicated she had not been invited to or attended a care plan meeting. Resident 60's record was reviewed on 8/31/22 at 2:25 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/16/22, indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF804Sep 1, 2022

  Based on interview, record review, and observation, the facility failed to ensure the temperature and palatability of food served for 7 of 7 residents reviewed for concerns with food temperatures, and for 1 of 1 test tray reviewed for temperature and palatability. Findings include: During an interview, on 8/26/22 at 10:42 a.m , Resident 26 indicated the food was nothing to write home about. I eat breakfast in my room and the food is cold, especially the scrambled eggs and oatmeal. During an interview, on 8/25/22 at 11:49 a.m., Resident 14 indicated he ate meals in his room and the food was cold. During an interview, on 8/26/22 at 10:26 a.m., Resident 69 indicated that sometimes food was not hot enough. The resident ate in the dining room. […]

• No harm, potential for more than minimal, patternF880Jul 13, 2021

  Based on observation, interview, and record review, the facility failed to follow CDC guidance during a pandemic and ensure infection control practices for COVID-19 were implemented to prevent the potential for spread of the virus for droplet isolation precautions for a resident (Resident 13) exhibiting signs and symptoms of a cough and congestion, failed to separate Resident 13's roommate (Resident 28) from continued potential exposure to her symptomatic roommate, failed to ensure staff wore appropriate personal protective equipment (PPE) while in droplet isolation rooms, failed to ensure staff sanitized their hands after doffing PPE, and failed to ensure unvaccinated staff wore medical goggles during resident care for 4 of 4 random observations of transmission based precautions and… […]