The Benjamin Healthcare Center

In the surveyor’s words

From the most serious findings on record at The Benjamin Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF921Jul 10, 2025

  Based on observations, records reviewed, and interviews, for one of three resident units (2-West Unit), which had a resident census of 27, nine of whom were identified to be at risk for elopement, the Facility failed to ensure they maintained a safe and functional environment for residents, staff, and visitors, when the alarm on the stairwell fire door malfunctioned, the alarm was removed, and then a staff member zip tied the fire door closed, preventing the door from opening in case of an emergency for seven days from 06/18/2025 through 06/24/2025. […]

• Actual harm, isolatedF689Nov 17, 2022

  Based on interview and record review the facility 1) failed to prevent an accident resulting in a burn for 1 Resident (#29) and 2) failed to follow a fall care plan resulting in injury for 1 Resident (#2) out of a total sample of 19 residents. Findings include: 1. For Resident #29 the facility failed to provide supervision and setup assistance with a meal in accordance with the plan of care, resulting in a burn. Resident #29 was admitted to the facility in July 2018 with diagnoses including ataxia and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF921Sep 10, 2025

  Based on observations, records reviewed and interviews, for three of three shower rooms utilized by the residents, the Facility failed to ensure it provided a safe, functional, and sanitary environment, when door locks to the shower rooms did not function properly, shower rooms were not clean, smelled musty, were observed with visible areas of mold, and the overhead ventilation system was nonfunctional.Findings include:The Facility Policy, Infection Prevention and Control Program, dated revised August 2016, indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The Policy indicated important facets of infection prevention includes the… […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2025

  Based on observation, record reviews and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically: 1. The facility failed to ensure frozen foods were maintained frozen. 2. The facility failed to ensure available food was not expired, and that food was dated and securely stored. 3. The facility failed to ensure the dietary staff practiced proper hand hygiene and handled food in a way to minimize possible cross-contamination. 4. The facility failed to ensure the dish machine met proper sanitation requirements when staff used expired test strips and the wrong test strips. 5. […]

• No harm, potential for more than minimal, widespreadF801May 23, 2024

  Based on staff interviews the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services (FSD). Findings Include: During an interview on 5/22/24 at 1:41 P.M., Dietary staff #1 said he was employed as a cook at the facility. Dietary staff #1 said that the FSD had resigned around September of 2023 and that the facility had not hired a replacement. [NAME] #1 said he was delegated responsibilities such as ordering food, scheduling staff, and conducting staff in-services in the absence of a Food Service Director. […]