Benson Heights Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Benson Heights Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF688May 6, 2026

  Based on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of Range of Motion (ROM) for 1 of 5 sampled residents (Resident 4) reviewed for limited ROM. Resident 4 experienced harm as evidenced by after discharge from specialized rehab services the resident was able to open/close their right hand and perform Active ROM (AROM) and now Resident 4's right hand developed a contracture due not implementing therapy gloves, staff not consistently assisting resident with AROM as assessed and care planned. […]

• Actual harm, isolatedF600Oct 30, 2023

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for resident to resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach, for Resident 1 who experienced an attempted sexual act by another resident who removed their brief (undergarment) and was found with their pants down on top of Resident 1 by facility staff, and resulted in Resident 1 being transferred to a hospital emergency room (ER) to undergo a sexual abuse examination. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF801May 6, 2026

  Based on interview and record review, the facility failed to ensure Staff H (Dining Services Manager) met the minimum qualifications to serve as the director of food and nutrition services when the facility had no qualified dietitian or other clinically qualified nutrition professional employed full-time. This failure placed residents at risk for unmet nutritional needs and for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services management.Findings included. […]

• No harm, potential for more than minimal, widespreadF803May 6, 2026

  Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 1 sample residents (Resident 15) reviewed for food concerns, and failed to implement a system to ensure residents were provided with the correct food portion sizes according to their assessed nutritional needs for 1 of 1 kitchen tray line observations. These failures placed residents at risk for unmet nutritional needs and a diminished quality of life.Findings included. <Facility Policy>According to the July 2018 facility's Food and Nutrition Services Menus and Therapeutic Diets policy, the facility would have and follow menus that met the nutritional and personal needs of the residents. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions for 1 of 1 kitchens and 1 of 1 unit refrigerators designated for resident use. The failure to ensure food was not expired, ensure proper food labeling, and ensure staff performed hand hygiene during food preparation placed residents at risk for foodborne illness and the spread of infection.Findings included. <Facility Policy>According to the facility's July 2018 Food and Nutrition Services Food Safety policy, food items would be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food in the refrigerator would be labeled and dated. Staff would practice good hygienic practices and techniques. […]