Benton Rehabilitation and Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF602Aug 16, 2024

  Based on interview and record review, the facility failed to prevent the misappropriation of resident trust funds and private checking accounts from V3, former Business Office Manager for 50 of 50 residents (R1-R50) reviewed for theft in a sample of 52. This failure resulted in checks written for cash on R1 through R50's pooled resident trust account, totaling $5515.19 and checks written from R1's individual checking account totaling $10,650. These actions would cause a reasonable person to have feelings of sadness, worry, stress and anguish while residing in a home where monetary theft occurred. The Immediate Jeopardy began on 12/21/23 when V3 wrote a $250 check for cash on R1's personal checking account, with no documentation as to what happened to the money. […]

• Actual harm, patternF692Jul 8, 2022

  Based on interview, observation, and record review the facility failed to provide the prescribed diet, nutritional supplements and the appropriate portion size of protein documented on the approved menu for 4 of 10 residents (R10, R26, R7, & R35) reviewed for weight loss in the sample of 40. This failure further contributes to continued harm to R10, R26, R7 and R35, who have a documented history of severe weight loss. Findings Include: 1. R10's facility's document titled, Profile Face Sheet documents that R10 was admitted to the facility on [DATE]. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & Levillocytosis. […]

• Actual harm, isolatedF689Feb 23, 2024

  Based on observation, interview, and record review the facility failed to implement interventions and follow facility policies to prevent falls for three of three residents (R1, R2, and R3) reviewed for falls in the sample of 3. These failures resulted in R1 having injuries including a dislocated shoulder and an intertrochanteric fracture of the right femur. The findings Include: 1. R1's Face Sheet documents an admitted [DATE] with diagnoses including: Hemiplegia following unspecified cerebrovascular disease affecting right dominated, Essential hypertension, End stage renal disease, Type 2 diabetes with diabetic peripheral angiopathy, Unspecified sequelae of cerebral infarction, Unspecified systolic heart failure, Peripheral vascular disease, unsteadiness on feet, Cerebral infarction,… […]

• Actual harm, isolatedF689Apr 11, 2023

  Based on interview and record review, the facility failed to provide supervision to an intoxicated resident with a history of falls to prevent future falls, failed to investigate the source of an unwitnessed injury as a potential suicide attempt, and failed to update a resident's care plan to include new interventions for episodes of intoxication for 1 resident(R1) of 4 residents reviewed for accidents and supervision in the sample of 4. This failure resulted in R1 sustaining a fall on 12/19/22 resulting in a fractured left hip and sustaining a fall on 3/24/23 resulting in sutures and staples to the back of the head and neck. […]

• Actual harm, isolatedF686Jan 27, 2023

  Based on observation, interview, and record review the facility failed to identify, monitor, and treat a pressure wound for 1 (R3) of 3 residents reviewed for wounds in the sample of 3. This failure resulted in R3 developing at minimum a Stage II pressure wound to the left buttock after admission with no consistent assessments or treatments documented to determine the actual wound onset. Findings Include: R3's Profile Face Sheet documents an Original admitted to the facility on [DATE]. R3's Braden Scale for Predicting Pressure Ulcer Risk dated 12/18/22 documents a total score of 15, indicating R3 was at high risk. […]