Benbrook Nursing & Rehabilitation Center
Benbrook Nursing & Rehabilitation Center in Benbrook, TX — inspection on August 9, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/09/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Benbrook Nursing & Rehabilitation Center
1000 McKinley St Benbrook, TX 76126
SUMMARY STATEMENT OF DEFICIENCIES
that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff have received training on handling and reporting elopements/code silver training. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/09/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Benbrook Nursing & Rehabilitation Center
1000 McKinley St Benbrook, TX 76126
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
had been verified as fixed. In an interview on 8/09/25 at 2:26 pm, the ADM reported that he and the DON received training on 8/09/25 by the regional LNFA COO who went over all the trainings that they were to provide to staff, the plan of removal, and reportable guidelines and investigation.
The ADM reported he will report all reportable events immediately to the LNFA COO for investigation oversight, and if the COO is out of office, he will notify the CEO. He reported that as an Administrator he plans to talk to the staff more thoroughly and watch how he is talking to staff as something that was meant as a precautionary statement had been taken as a threat. He stated he intended to make sure that documentation is thorough.
The ADM reported that this was IJ as the resident was at risk due to possible elopement that wasn't reported in a correct or timely manner and there was an allegation that the Administrator threatened retaliation against staff for documenting and reporting. In an interview on 8/09/25 at 4:17 PM the DON stated that she and the ADM had received training from corporate on all training involved in the plan of care and all the in-service trainings that they were to provide to the staff.
She stated that she feels the reeducation of staff on all the topics will make a difference and that now the corporate number has been made available to staff.
The DON stated that this situation was an IJ because there was an allegation of an elopement that was not processed or addressed, and it was an IJ because the situation presented a risk.
She reported she will be questioning staff regarding elopements during clinical meetings going forward and will be monitoring to ensure that any PRN staff who have not received the appropriate training are not allowed to work. On 8/09/25 at 2:46 pm the ADM was notified the IJ was removed.
However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate their corrective actions.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.