KENT, WA - Benson Heights Rehabilitation Center faced multiple compliance issues during a February 2025 inspection, including failures to provide ordered medical devices for hand contractures, inadequate weight monitoring for a resident with heart failure, and incomplete safety assessments for residents with beds positioned against walls.
Ordered Hand Therapy Device Not Provided
Inspection findings revealed significant gaps in implementing prescribed interventions for Resident 61, who required extensive daily care due to severe memory impairment, dementia, and existing open skin lesions. The facility received a physician's order on December 18, 2024, directing staff to apply a specialized therapy device called a "Therapy Carrot" - a carrot-shaped fabric tool designed to maintain space in hands that no longer open freely due to contractures.
The order specified the device should be placed in each hand for four hours per shift, with staff instructed to switch between hands or adjust duration based on the resident's tolerance. The facility incorporated this intervention into the resident's care plan for preventing skin breakdown, acknowledging the importance of this measure.
However, observations conducted over multiple days revealed the ordered intervention was not being implemented. On February 18, 2025, at 1:43 PM, inspectors noted signage above the resident's bed informing staff to use the Therapy Carrot instead of the previously used sheepskin palm protector. Despite this posted reminder, no therapy device was observed in place. Follow-up observations on February 24 at 12:13 PM, 12:35 PM, and 1:17 PM consistently showed the resident without the ordered device in either hand.
When the Director of Nursing reviewed the resident's medical record during the inspection, they acknowledged the facility lacked any documentation system for staff to record when they provided the Therapy Carrot, how long the resident tolerated it, or when it was removed. The nursing director confirmed that based on the order's specifications, the resident should have had the device in place during the middle of the day. Upon examining the resident's hands, the director stated the Therapy Carrot should have been present but was not.
Hand contractures develop when muscles, tendons, and tissues in the hand tighten and shorten, causing the fingers to curl into the palm. This condition commonly occurs in residents with severe cognitive impairment who cannot actively use their hands. Without proper positioning devices, the constant flexed position creates warm, moist environments between the fingers and palm where skin can break down. These pressure areas can develop into painful wounds that are difficult to heal and carry risks of infection, particularly concerning for residents who already have compromised skin integrity.
Therapy devices like the Therapy Carrot work by gently maintaining space within the closed hand, preventing skin-to-skin contact that traps moisture and creates pressure points. The four-hour duration specified in the order represents a balance between providing adequate prevention while allowing periods of rest and position changes. Alternating between hands ensures both receive appropriate intervention while preventing potential complications from prolonged device use in a single location.
Critical Weight Monitoring Gap for Heart Failure Patient
The inspection identified failures in monitoring protocols for Resident 82, who had documented heart failure and edema requiring diuretic medications. The resident's care plan, established in June 2024, specifically directed staff to monitor weight daily and watch for lower extremity swelling - standard interventions for managing heart failure and fluid retention.
During a February 20, 2025 observation, inspectors documented the resident had pitting edema in both lower legs - a concerning sign of fluid accumulation where pressing on the swollen tissue leaves a temporary indentation. Despite this visible indication of fluid retention and the care plan's requirement for daily weight monitoring, staff acknowledged they were only obtaining the resident's weight weekly rather than daily as ordered.
The Unit Manager confirmed during the inspection that the facility should have been monitoring the resident's weight daily. The manager explained the critical importance of this monitoring, noting that excessive fluid retention can cause cardiac overload and fluid accumulation in the lungs - potentially life-threatening complications.
Daily weight monitoring serves as an essential early warning system for heart failure patients. Weight gain of even two to three pounds over a few days can indicate fluid retention before more serious symptoms develop. This simple measurement allows healthcare providers to adjust diuretic medications promptly, preventing the progression to more severe complications such as pulmonary edema (fluid in the lungs) or acute heart failure exacerbation requiring hospitalization.
The presence of pitting edema in both lower extremities indicated the resident was already experiencing significant fluid retention. Without daily weight tracking, staff lacked crucial data to identify worsening trends and communicate changes to the physician for timely medication adjustments. This monitoring gap placed the resident at increased risk for preventable complications and potential hospital transfers.
Safety Assessment Failures for Bed Positioning
The facility failed to complete required safety assessments before positioning beds against walls for three residents - Residents 4, 63, and 70. While placing beds against walls can be an appropriate accommodation when properly evaluated, the practice requires careful assessment to prevent entrapment risks.
Resident 4 had a history of stroke and morbid obesity documented in their admission assessment. Resident 63 experienced general muscle weakness, unsteadiness, and mobility difficulties. Resident 70 required assistance with personal care due to lack of coordination and muscle weakness. Despite these documented physical limitations, the facility positioned each resident's bed against the wall without conducting the required safety evaluation.
Observations on multiple dates between February 18-19, 2025, confirmed beds positioned against walls for all three residents. Record reviews revealed no documentation of safety assessments addressing entrapment risks or discussing alternatives with the residents. The Unit Manager acknowledged during the inspection that the facility did not complete the required assessments but should have done so to ensure resident safety.
The gap between the bed and wall can create an entrapment zone where residents with limited mobility or impaired cognition can become wedged and unable to free themselves. Residents with weakness or coordination difficulties face particular risks because they may lack the physical capability to reposition themselves if they roll toward the wall. Safety assessments consider factors including the resident's cognitive status, physical abilities, bed mobility, and whether the potential benefits of wall positioning outweigh entrapment risks.
Facility policy required informing residents or their representatives about the risks and benefits of bed positioning choices and obtaining consent prior to implementation. The policy emphasized working with residents to understand their preferences while discussing options and mitigating identified risks through updated care plans. The absence of documented assessments indicated these conversations and safety evaluations did not occur.
Unsecured Storage of Hazardous Materials
On February 21, 2025, at 8:30 AM, inspectors found the north utility room door unlocked with hazardous materials stored in open, accessible cabinets. The room contained razors, hygiene supplies, and disinfectant cleaners - items that could pose safety risks if accessed by cognitively impaired residents. The Unit Manager acknowledged the utility room should remain locked but was not, explaining these rooms required security because the chemicals and razors stored inside should not be openly accessible to residents.
Cleaning chemicals can cause chemical burns, poisoning, or respiratory problems if ingested or improperly used. Razors present obvious cutting and injury risks, particularly concerning for residents taking blood-thinning medications or those with dementia who may not use items appropriately. Facility policy identified potentially hazardous items accessible to vulnerable residents as safety concerns requiring containment to protect residents from exposure.
Inadequate Supervision for Resident Leave
The facility failed to provide appropriate supervision when Resident 90 left the facility unaccompanied despite a physician's order requiring the resident to leave only with a responsible person. The resident had documented memory impairment, post-traumatic stress disorder, and serious infections requiring intravenous antibiotics through a PICC line.
The resident told inspectors they left the facility at 4:30 PM and returned at 8:15 PM, traveling alone via taxi to shop, have drinks with a friend in another city, and check mail at an apartment. The resident acknowledged being told facility policy required accompaniment when leaving but admitted they falsely claimed to have permission to leave alone when signing out.
The Unit Manager stated the physician's order requiring accompaniment may have been incorrect and should have been verified but was not. The Administrator acknowledged awareness the resident left unaccompanied and stated the resident expressed a desire to go alone. However, the Administrator was unaware of the physician's order and suggested it may have been related to the resident's PICC line for antibiotic treatment.
The presence of a PICC line for treating serious bone and skin infections creates legitimate supervision concerns. These lines require proper care to prevent infection or dislodgement, and residents using them should avoid certain activities. The combination of memory impairment, substance abuse history, and serious medical treatment created a clinical picture warranting supervised community access. The care plan failed to address interventions for the resident leaving the facility unaccompanied, and staff did not enforce the physician's order requiring supervision.
Additional Issues Identified
The inspection documented the facility's policy requiring systems to address resident risks and environmental hazards while minimizing accident likelihood. The policy specified that supervision should be used to mitigate accident risks and that care plans would be updated to honor resident choices while addressing safety concerns.
The facility's quality of care policy, dated November 2017, committed to providing care and services consistent with professional standards to prevent skin breakdown for residents with skin impairments. The policy indicated the facility would provide preventative measures as needed to maintain skin integrity.
An undated edema management policy identified weight monitoring as an intervention for heart failure - the very intervention that was not being implemented for Resident 82 despite the documented need.
The February 2025 inspection identified systemic gaps between the facility's written policies and actual practice. Staff failed to implement ordered interventions, complete required safety assessments, secure hazardous materials, and ensure appropriate supervision - placing residents at risk for preventable injuries, infections, and medical complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benson Heights Rehabilitation Center from 2025-02-25 including all violations, facility responses, and corrective action plans.
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