Bennett Hills Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Bennett Hills Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Mar 11, 2021

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when nursing staff did not perform proper hand hygiene during resident cares and properly put on their face mask and face shield during their shift. This was true for 2 of 7 residents (#8 and #10) observed during resident cares and 1 of 6 staff (LPN #2) observed for wearing PPE. These failures had the potential to impact all residents, staff, and visitors entering the facility by placing them at risk of infection due to cross contamination. Findings include: 1. […]

• Actual harm, patternF684Mar 11, 2021

  Based on observations, policy review, review of I&A reports, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were met related to management of urinary tract infections, physician notification of change in condition, and neurological assessment. This was true for 4 of 9 residents (#1, #2, #7, and #8) reviewed for standards of practice. Specifically: * Resident #7 was harmed when treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures culminating in Resident #7's transfer to a hospital where he was diagnosed with [CONDITION(S)] (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). […]

• Actual harm, patternF686Mar 11, 2021

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 4 of 5 residents (#1, #2, #6, and #8) reviewed for quality of care. This failure resulted in harm when Resident #8's pressure ulcer on her coccyx developed an infection and required her to take an antibiotic by injection and Resident #6 developed a blister on her right thigh. […]

• Actual harm, patternF689Mar 11, 2021

  Based on staff interview, policy review, record review, and review of I&A reports, the facility failed to ensure sufficient supervision of residents to prevent falls. This was true for 3 of 4 residents (#1, #7, and #8) reviewed for falls.This resulted in harm to Resident #1 when, after a fall, her decreased alertness was not acted upon in a timely manner. This deficient practice resulted in harm to Resident #7 when he sustained multiple falls with injuries without appropriate supervision and interventions to prevent falls. Resident #8 was harmed when she experienced two unwitnessed falls and sustained bruises, abrasions, and lacerations which were required to be sutured as a result of the falls. […]

• Actual harm, isolatedF689Apr 30, 2026

  Based on record review, review of the State Agency's Long-Term Care Reporting Portal, staff interviews, and review of the facility policies, the facility failed to ensure residents were free from accidents. This was true for 1 of 2 residents (Resident #8) reviewed for transportation. This failure caused injury for this resident. Findings include:The facility's Transportation Policy/Procedure policy revision date 12/30/25, documented Loading Passengers - insert the four tie down mechanisms to the fixture on the floor. Make certain that they are secured, and locked in. The facility's Fleet Safety Program manual revision date 4/14/21, documented employees are expected to operate vehicles safely to prevent accidents which may result in injuries and property loss. […]