Lake Bennet Center for Rehabilitation & Healing

In the surveyor’s words

From the most serious findings on record at Lake Bennet Center for Rehabilitation & Healing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 17, 2025

  Based on interview, and record review, the facility neglected to ensure nurses implemented physician's orders for diagnostic testing, failed to notify the physician of any changes of status including refusal of care, and neglected to ensure the resident received the provision of necessary care and services; additionally, the facility failed to complete a thorough investigation for possible neglect for 1 of 6 residents reviewed for neglect, of a total sample of 6 residents, (#1). On [DATE], resident #1 was admitted to the facility from the hospital. On [DATE], the resident was re-hospitalized and required mechanical ventilation (life support to breathe) in the Intensive Care Unit (ICU) due to critically low blood pressure and septic shock from a Urinary Tract Infection (UTI). […]

• Immediate jeopardy, isolatedF684May 17, 2025

  Based on interview, and record review, the facility failed to attain or maintain the resident's highest practicable physical well-being by failing to ensure nurses implemented physician's orders for diagnostic testing, notified the physician, and ensured provision of necessary care and services for 1 of 6 residents reviewed for Quality of Care, of a total sample of 6 residents, (#1). The facility failed to implement a physician's order for Urinalysis with Culture and Sensitivity (UA/CS) for resident #1, failed to notify the physician that the ordered diagnostic test was not completed, and failed to follow up on the missing laboratory result. Additionally, the physician/provider did not recognize or act upon the absence of the test result. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions. Findings: On 08/04/2025 at 9:57 AM, during kitchen tour observation, Dietary Aide J was observed putting a dish rack containing dishes into the dish machine while [NAME] L removed items from the dish machine area and placed them with other eating items in the kitchen. The temperature dial on the dish machine showed temperature to be 110 degrees Fahrenheit (F). On 8/04/2025 at 10:03 AM, the Certified Dietary Manager (CDM) stated the dish machine was a low temperature machine and should wash at 120 degrees F or higher. […]

• No harm, potential for more than minimal, patternF688Feb 18, 2022

  Based on observation, interview and record review, the facility failed to follow plan of care for splint application for 2 of 5 residents reviewed for mobility of a total sample of 44 residents, (#104, #11). Findings: 1. Resident #104 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with reference date 01/10/22 revealed resident #104 had moderately impaired cognition and required extensive assistance of 1 person for bed mobility, dressing, personal hygiene and bathing. She was totally dependent on 1 staff for toilet use. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF755Aug 7, 2025

  Based on interview, and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 39 residents, (#63).Findings:Review of the medical record revealed resident #63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, heart valve insufficiency, and hyperlipidemia. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/29/25 revealed resident 63 had an active diagnosis of hypertension. […]