Benbrook Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Benbrook Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 9, 2025

  Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to prevent Resident #1 from eloping from the facility on an unknown date in July 2025. The failure could place residents at risk for possible elopement, serious injuries, and harm. An Immediate Jeopardy (IJ) was identified on 08/08/25. The IJ template was provided to the facility on [DATE] at 3:32 pm. […]

• Immediate jeopardy, isolatedF689Dec 7, 2023

  Based on observations, interviews, and record review, the facility failed to provide adequate supervision for 1 of 10 residents (Resident #1) reviewed for wandering and elopement risk. The facility failed to implement effective interventions for Resident #1 identified as at-risk for elopement and had a history of elopement. On 12/03/23 at approximately 1:15 PM, Resident #1 was demonstrating exit-seeking (actively trying to leave the boundaries of a particular area) behaviors by attempting to go out the exit door when the alarm sounded off. LVN A verbally redirected Resident #1 to come to the nurse's station. On 12/03/23, Resident #1 eloped (an unauthorized departure of a resident from an around-the-clock care setting) from the secured unit unnoticed by facility staff. […]

• Actual harm, isolatedF695Dec 11, 2022

  Based on observations, interviews, and record reviews, the facility failed to provide timely emergency respiratory care consistent with professional standards of practice, including maintaining training for nursing staff regarding expectations for suctioning residents in the on-site dialysis center, for a resident in respiratory distress in the facility's in-house, contracted dialysis center for one (Resident #1) of one resident reviewed for tracheostomy care. 1. Facility staff failed to respond immediately to a request by contract dialysis staff to provide suction for Resident #1 when she had respiratory distress on 10/25/22, at which time Resident #1's distress increased, and she stopped breathing and became unresponsive for an estimated 45 seconds. […]

• No harm, potential for more than minimal, widespreadF804Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received food that was appetizing, appealing, and proper temperature prior to serving.The facility failed to ensure milk was at a safe temperature before serving. The facility failed to ensure the dinner roll item was appealing and appetizing food item. The facility failed to ensure the baked potatoes were appealing texture. This failure could result in residents' not being provided food that is nutritious and appealing, resulting in a decreased quality of life.Findings include: Record review of Resident #16's face sheet dated 09/11/2025, revealed a [AGE] year-old woman admitted on [DATE] from a psychiatric hospital. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure the stand-by freezer food items were dated, labeled, and secured.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and secured.3. The facility failed to ensure the dry storage food items were dated, labeled, and procured.4. The facility failed to ensure that canned good food items were free of dents.5. […]