Benbrook Nursing & Rehabilitation Center
Inspection Findings
F-Tag F0584
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-09-11.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-15.
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the police and that was when the Administrator took over. She stated she documented the incident in the progress notes. Surveyor asked LVN D to show where in the EHR it was documented this happened on 09/05/25, LVN pulled up the note dated 8/29/25. She stated she knew it was one of those days. She stated
she did not complete an incident report or witness statement. She said she kept Resident #49 and Resident #87 separated on her shift the week of 8/29/25 through 9/5/25 and Resident #87 stayed in bed most of the morning that week. She stated Resident #87 was moved to a different hall on 09/08/25 but did not know why he moved. LVN D stated she was supposed to report all abuse to the abuse coordinator immediately.
Interview on 09/11/2025 at 11:15 am, the Administrator stated he reported the incident because he got a call that police were at the facility and he walked back to talk to the residents involved, the nurse and other onlookers. He stated he thought another resident had called the police and she was saying he's going to hit somebody so that triggered him to report (to HHSC). The Administrator stated he read the note dated 08/29/2025 written by LVN D, and the way it read was like adults arguing. When Surveyor asked for clarification on which incident the initial reportable to HHSC was for on 09/06/25, the Administrator was not able to provide an explanation. When asked if the incident on 8/29/25 should have been reported, he stated
it read like adults arguing. He stated if there was a separate incident, maybe that's why they moved Resident #87 over the past weekend. Interview on 09/11/25 at 7:37 pm, the Administrator stated he had no new information related to the incident. He stated reporting to the state agency (HHSC) was to ensure guidelines were followed and incidents were handled appropriately, if not something could fall through the cracks and the outcome could be worse. He stated if staff witnessed abuse and did not report to him, the risk for verbal abuse could be lasting psychological harm that may not be noticed. He stated he expected staff to document incidents in the EHR and monitor residents after an incident. He stated residents could be monitored one to one or have every 15 minutes and would be monitored by the staff assigned to the hall.
Record review of facility policy titled, Abuse Investigation and Reporting revised July 2017, revealed in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Benbrook Nursing & Rehabilitation Center
1000 McKinley St Benbrook, TX 76126
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
police and that was when the Administrator took over. She stated she documented the incident in the progress notes. Surveyor asked LVN D to show where in the EHR it was documented this happened on 09/05/25, LVN pulled up the note dated 8/29/25. She stated she knew it was one of those days. She stated
she did not complete an incident report or witness statement. She said she kept Resident #49 and Resident #87 separated on her shift the week of 8/29/25 through 9/5/25 and Resident #87 stayed in bed most of the morning that week. She stated Resident #87 was moved to a different hall on 09/08/25 but did not know why he moved. LVN D stated she was supposed to report all abuse to the abuse coordinator immediately.
Interview on 09/11/2025 at 11:15 am, the Administrator stated he reported the incident because he got a call that police were at the facility and he walked back to talk to the residents involved, the nurse and other onlookers. He stated he thought another resident had called the police and she was saying he's going to hit somebody so that triggered him to report (to HHSC). The Administrator stated he read the note dated 08/29/2025 written by LVN D, and the way it read was like adults arguing. When Surveyor asked for clarification on which incident the initial reportable to HHSC was for on 09/06/25, the Administrator was not able to provide an explanation. When asked if the incident on 8/29/25 should have been reported, he stated
it read like adults arguing. He stated if there was a separate incident, maybe that's why they moved Resident #87 over the past weekend. Interview on 09/11/25 at 7:37 pm, the Administrator stated he had no new information related to the incident. He stated reporting to the state agency (HHSC) was to ensure guidelines were followed and incidents were handled appropriately, if not something could fall through the cracks and the outcome could be worse. He stated if staff witnessed abuse and did not report to him, the risk for verbal abuse could be lasting psychological harm that may not be noticed. He stated he expected staff to document incidents in the EHR and monitor residents after an incident. He stated residents could be monitored one to one or have every 15 minutes and would be monitored by the staff assigned to the hall.
Record review of facility policy titled, Abuse Investigation and Reporting revised July 2017, revealed in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility;b. The local/State Ombudsman;c. The Resident's Representative (Sponsor) of Record;d. Adult Protective Services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's attending physician; andg. The facility medical director.2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; orb. twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0656
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-09-11.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0684
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0693
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0761
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-11.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0804
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-09-11.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0812
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-11.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0813
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0813 during a standard health inspection conducted on 2025-09-11.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0814
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-09-11.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Dispose of garbage and refuse properly.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
F-Tag F0947
Federal health inspectors cited Benbrook Nursing & Rehabilitation Center in Benbrook, TX for a deficiency under regulatory tag F-F0947 during a standard health inspection conducted on 2025-09-11.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of Benbrook Nursing & Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-13.
Benbrook Nursing & Rehabilitation Center in Benbrook, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Benbrook, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Benbrook Nursing & Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.