Benderson Family Skilled Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Benderson Family Skilled Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Jun 12, 2025

  Based on observation, interview and record review, the facility failed to ensure quality of care by not following physicians' orders for 3 residents (#13, #133, and #29) of 3 residents reviewed for following physician's orders. The findings included: Review of the Policy for Physician Services dated 11/28/17 #8 revealed, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF842Jun 12, 2025

  Based on observation, interview and record review, the facility failed to ensure accurate medical records for 2 residents (#13 and #133) of 3 residents reviewed for accuracy of medical records. The findings included: 1. Review of the medical revealed Resident #13 was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) with a target date of 5/12/25 revealed Resident #13's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The MDS revealed Resident #13 did not reject care and was dependent on staff for dressing of the lower body. The MDS diagnoses included, but was not limited to, hyperlipidemia, dementia, and asthma. Review of the physician's orders revealed an active order dated 3/14/25 for Ted hose on during day, off at night. […]

• No harm, potential for more than minimal, isolatedF919Jan 13, 2025

  Based on staff interview, resident interview, observations and resident medical record review, it was determined that the facility failed to ensure the residents' right to call light access for two residents (Resident #3 and Resident #4) out of eight residents observed during the survey. The findings included: During an initial tour of the facility which commenced on 1/13/25 at 10:00 a.m., Resident #3 was observed sitting up in her wheelchair on the window side (left side) of her bed. There was no call light observed within her reach. In an interview with Resident #3 conducted on 1/13/25 at 10:05 a.m., she was asked how she would get the staff's attention if she needed anything. She stated I guess I'd push the button. Oh, wait this is the TV remote. I don't know where the button is. […]

• No harm, potential for more than minimal, isolatedF645Jan 5, 2024

  Based on clinical record review, and staff interview, the facility failed to ensure 1 (Resident #30) of 1 sampled resident with admitting diagnoses of serious mental illness had a complete and accurate Preadmission Screening and Resident Review (PASRR). The findings included: Clinical record review revealed Resident #30 was admitted to the facility on [DATE]. The admitting diagnoses included Major Depressive Disorder, single episode, moderate, Generalized anxiety disorder, and Psychosis. The Admission Minimum Data Set (MDS) assessment with an assessment reference date of 11/29/23 listed diagnoses of anxiety disorder, Depression and Psychotic disorder. Review of the undated level 1 PASRR showed Resident #30 had a primary diagnosis of dementia, and was not a provisional admission. […]

• No harm, potential for more than minimal, isolatedF578Mar 17, 2022

  Based on medical record review, review of facility's policies and procedure, staff, and resident interviews the facility failed to ensure 3 (Residents #4, #5 and #13) of 16 residents reviewed for advance directive were informed and provided written information of advance directive rights and ensure their advance directive wishes were followed. The findings included: The facility's policy and procedure titled, Resident Right - Advanced Directive Tracking Program dated [DATE] noted, It is the facility policy to honor the advance directives of all residents and to make information available to the resident on how to prepare such directives, should the resident not have them in place or update their existing directives. Procedure: 1. […]