Lake Bennet Center For Rehabilitation & Healing

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. She verified the temperature gauge registered at 110 degrees F and not 120 degrees F as noted on the data plate on the machine. She stated a repairman had been there the previous Friday and machine read 120 degrees F at that time. The CDM ran a rack through the machine again and the temperature gauge did not move past 110 degrees F. Dietary Aide J stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the Order Summary Report for August 2025 revealed resident #63 had a physician order dated 7/21/25 for Metoprolol Tartrate 12.5 milligrams to be given two times a day for beta-blocker. The order included parameters to hold the medication if resident #63's heart rate was less than 55 beats per minute or her Systolic Blood Pressure (SBP) was less than 120. Metoprolol is a beta-blocker medication used to treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized Comprehensive Care Plan to include an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheters, of a total sample of 6 residents, (#3). Findings: Review of the medical record revealed resident #3, an [AGE] year old female was admitted to the facility from an acute care hospital on [DATE]. She had diagnoses that included wedge compression fracture of thoracic (mid-spine) and lumbar (lower spine) vertebrae, and Urinary Tract Infection (UTI). The Minimum Data Set (MDS) Comprehensive admission 5-day Assessment with an Assessment Reference Date (ARD) of 12/13/24 noted during the look back periods, resident #3 scored 10 out of 15 on the Brief Interview for Mental Status that indicated she was moderately cognitively impaired. The resident required staff assistance to complete Activities of Daily Living (ADLs) and the use of an indwelling urinary catheter appliance. During the 7-day look back period, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to conduct a thorough investigation for a bruise of unknown origin for 1 of 6 residents reviewed for accidents, out of a total sample of 39 residents, (#50). Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, dementia, mixed anxiety disorders, long-term use of anticoagulants and cognitive communication deficit. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 10/12/23 revealed resident #50 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated she had severe cognitive impairment. Resident required assistance with activities of daily living and used a wheelchair for mobility. A weekly skin assessment dated [DATE] indicated resident #50 had a discoloration on her left wrist. Review of resident #50's electronic medical record revealed a nursing progress note dated 12/30/22 which indicated resident #50 had a discolored area to her left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and/or revise the comprehensive fall care plan to reflect accurate, appropriate, and individualized interventions related to falls for 1 of 3 residents reviewed for falls of a total sample of 39 residents (#37). Findings: Resident #37 was admitted to the facility on [DATE] with diagnoses to include dementia, depression, anxiety, and long-term use of anticoagulants (blood thinner). The Minimum Data Set (MDS) significant change assessment, with an assessment reference date of 10/27/23 revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 01/15 which indicated she had severe cognitive impairment, she was dependent on staff for her daily care, and she used a wheelchair for mobility. On 11/30/23 at 10:42 AM, resident #37's falls were reviewed with the Risk Manager (RM) and revealed the following information: On 1/16/23 at 2:40 PM, resident#37 was found on the floor in her room. The resident complained of pain in ribs and hips.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide adequate supervision and assistance to prevent avoidable falls for 1 of 3 residents reviewed for falls out of a total sample of 39 residents, (#83). Findings: Review of medical record revealed resident #83 was admitted to the facility on [DATE] with diagnoses to include heart failure, difficulty walking, muscle weakness, osteoarthritis of the right knee, and venous insufficiency. Review of physician note dated 12/7/22 at 9:11 PM, showed resident #83 had a history of falls. Review of the physician orders from December 2022 to November of 2023 showed an order for a silent bed alarm and resident #83 received Apixaban 2.5 mg by mouth twice a day, a medication that decreases the body's ability to clot (2023, December 9), retrieved December 1, 2023, from https://www.webmd.com/dvt/anticoagulant. Review of the admission Minimum Data Set (MDS) assessment for resident #83, with an assessment reference date (ARD) of 5/11/23, revealed a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate and appropriate care and services by not following the physician order for a resident who received gastric tube (GT) feedings for 1 of 3 resident reviewed out of a total of 39 sample residents, (#107). Findings: Review of Resident #107's medical record revealed she was admitted to the facility on [DATE] with diagnoses to include gastrostomy, severe protein calorie malnutrition, surgical aftercare of the digestive system, and dysphagia oropharyngeal phase. The resident's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/18/23 noted the resident has a Brief Interview for Mental Status (BIMS) score of 10 which is moderately impaired. She requires dependent to maximal care of staff for activities of daily living and requires a tube feeding to meet her nutritional needs due to loss of liquids when eating, coughing, choking during meals, pain, and difficulty with swallowing. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accuracy of documentation in the electronic health record for changing of the enteral tube tubing, water bag, and water bag tubing for 1 of 3 residents reviewed for documentation accuracy of tube feedings, out of a total sample of 39 residents (#107). Findings: Review of the medical record revealed Resident #107 was admitted to the facility on [DATE]. Her diagnoses included surgical aftercare digestive system, dysphagia oropharyngeal phase, attention to gastrostomy and anarthria. Further review of the medical record showed a Physician Order dated 9/14/23 for an Enteral Feed Order with every night shift to change enteral feeding syringe, storage container, and tubing daily. Review of the Medication Administration Record (MAR) dated 11/25/23 at 11:00 PM, showed documentation signature initials for Licensed Practical Nurse (LPN) T and on 11/26/23 at 11:00 PM, a documentation signature initials for LPN U as having changed Resident #107 enteral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 of Parkinson's disease, dementia, quadriplegia and osteoporosis. 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 dated 7/20/21 read Apply resting hand splint to right hand, ON in AM and OFF in PM as tolerated. Monitor for pain, discomfort, hand hygiene, splint hygiene, nail care and skin integrity every shift. A care plan initiated on 10/02/20, and revised on 12/24/21 noted resident #104 had self-care performance deficit which required assistance with bed mobility, toileting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify multiple bruises on a resident's neck/chest for 1 of 3 residents reviewed for non-pressure skin conditions out of a total sample of 44 residents, (#65). Findings: Review of resident #65's medical record documented she was admitted to the facility on [DATE] with diagnoses of stroke, anemia and atrial fibrillation with long-term use of anticoagulants. Observations conducted on 02/14/22 at 2:30 PM, 02/15/22 at 5:22 PM, 02/16/22 at 9:50 AM, 1:35 PM, and 5:27 PM and on 02/17/22 at 10:12 AM, noted the resident had multiple (7) circular purple/red bruises on her right upper chest/neck area. The resident was not able to verbalize how she got the bruises but indicated she did not have any pain at the site. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had severe cognitive impairment, required extensive assistance with Activities of Daily Living, (ADL) limited assistance with personal hygiene and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for tube feedings (TF) for 1 of 4 residents reviewed for tube feedings of a total sample of 44 residents, (#90). Findings: Resident #90 was admitted to the facility on [DATE] with his most recent readmission on [DATE]. His diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, dementia, aphasia, dysphagia emphysema, severe protein-calorie malnutrition, depression, and atrial fibrillation. Review of the resident's clinical records showed a physician's order dated 2/01/22 which read, every night shift Enteral: Closed system container- Change feeding administration set with each new bottle; label the formula container, syringe, and administration set with resident's name, date, time, and nurse's initials. The Medicare 5-day Minimum Data Set (MDS) assessment with assessment reference date of 1/02/22 indicated the resident was rarely/never understood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) therapy was administered per the physician's order for 1 of 3 residents (#51) and failed to obtain physician orders for O2 therapy for 1 of 3 residents reviewed for oxygen therapy, (#90) of a total sample of 44 residents. Findings: 1. Resident #51 was admitted to the facility on [DATE] with a recent readmission of 2/12/22. Her diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, acute and chronic respiratory failure with hypercapnia, chronic diastolic (Congestive) heart failure, and Coronavirus Disease 2019. The resident's physician orders dated 2/13/22 noted oxygen at 2 Liters via nasal cannula (N/C) continuously. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 12/20/21 revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 15/15, and indicated the resident used O2. Observations on 2/14/22 at 1:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication was not left at the bedside unattended for 1 of 17 residents on the 200 unit, out of a total sample of 44 residents, (#124). Findings: Resident #124 was admitted to the facility on [DATE] with diagnoses including gastric ulcer, diverticulosis and cognitive communication deficit. Review of the medical record revealed a Brief Interview for Mental Status assessment dated [DATE] which indicated the resident was cognitively intact with a score of 15/15. Review of the physician orders for February 2022 revealed resident #124 had an order for Carafate (Sucralfate) Tablet 1 gram (gm) to be given three times a day for stomach acid. Sucralfate is a prescription medication used to treat ulcers by sticking to the ulcer sites and protecting them from acids, enzymes and bile salts (retrieved on 2/18/22 from www.drugs.com). On 2/16/22 at 9:28 AM, resident #124 was observed sitting on the edge of her bed with her overbed table in front…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician order was obtained for advanced directive/code status for 1 of 2 residents reviewed for advanced directives of a total sample of 44 residents, (#363). Findings: Review of resident #363's medical record documented she was admitted to the facility on [DATE] with diagnoses of thoracic fracture, and and spinal stenosis lumbar region. On 02/15/22 at 11:24 AM, a review of the resident's medical record did not reveal an order for advanced directive/Code Status. 02/15/22 at 1:33 PM, a review the Advance Directives book for the 100 hall revealed no physician order for resident #363's code status, Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) from the hospital documented the resident's wishes for full code status. Review of the Social Service note dated 02/10/22 at 3:06 PM, noted the resident wishes for full code. On 02/16/22 at 9:30 AM, the North Wing Unit Manager (UM) stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.