Benson Heights Rehabilitation Center
BENSON HEIGHTS REHABILITATION CENTER in KENT, WA — inspection on February 25, 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
F-F656 - develop/implement comprehensive care plan
Refer to
Findings included .
<Facility Policy>
According to the facility's July 2018, Quality of Care Respiratory Care Policy, the facility would assure respiratory care was provided to residents in need of such care.
The care would be consistent with professional stands standards of practice, the comprehensive person-centered care plan and resident's goals.
The facility would have procedures for response to adverse reactions to respiratory interventions, for respiratory assessments and should include when and how the assessment would be conducted and the type of documentation required.
<Providing Oygen Level Monitoring>
<Resident 38>
According to the 01/07/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 38 had respiratory failure with low blood (O2) levels.
Review of the revised 07/22/2024 Respiratory Failure Care Plan (CP) showed staff were to monitor for signs and symptoms of respiratory distress and report these findings to the provider.
The CP showed the symptoms staff were to report to the provider included increased respirations and decreased blood oxygen levels.
Review of a physician order dated 05/31/2024 showed staff were to monitor Resident 38's blood O2 levels every shift and to notify the provider of low O2 levels when Resident 38 was using supplemental O2.
Review of a February 2025 Treatment Administration Record (TAR) showed an order dated 02/05/2025 to provide O2 at a rate of 1 to 4 liters per minute every shift and to maintain O2 blood levels greater than 90%.
The February TAR showed on 02/01/2025, 02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, 02/10/2025, 02/11/2025 and 02/15/2025 O2 blood levels were at 90% or lower.
Review of progress notes in Resident 38's health record from 01/31/2025 through 02/18/2025 did not show documentation that the provider was notified of low O2 levels and did not show further documentation by the nurse practitioner regarding adjusting O2 level orders.
Interview on 02/21/2025 at 8:44 AM, Staff O (Certified Nursing Assistant) stated Resident 38 was not as responsive today and was coughing.
505519
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505519 B.
Wing 02/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Benson Heights Rehabilitation Center 22410 Benson Road SE Kent, WA 98031
Findings included .
<Facility Policy>
According to the facility's 11/2017 Quality of Care -policy, for residents with non-pressure-related skin impairments, the facility would provide care and services consistent with professional standards to prevent skin breakdown.
The policy showed the facility would provide preventative measures as needed to maintain skin integrity.
According to an undated facility policy titled, Edema Management, interventions for heart failure may include monitoring weights.
<Resident 61>
According to the 11/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 61 had a severe memory impairment and required total assistance with all daily routines.
The MDS showed Resident 61 had diagnoses including dementia, seizures, malnutrition, and an altered mental state.
The MDS showed Resident 61 required total assistance with all daily care and had open lesions.
Review of the physician's orders showed a 12/18/2024 order to apply Therapy Carrot [a carrot-shaped, fabric, therapy tool used to create space in a hand that no longer opens freely] for 4 hours in each hand then switch to the other hand.
Therapy carrots can be placed in one hand at a time as tolerated. every shift .
According to the 12/18/2024 Potential for skin breakdown Care Plan (CP) nursing staff should place the Therapy Carrot in each hand for 4 hours per hand or as tolerated.
The CP showed staff should place a Therapy Carrot in one hand at a time.
Record review showed there was nowhere for nursing staff to document they placed the Therapy Carrot in either hand, how long Resident 61 tolerated the Therapy Carrot, or when the Therapy Carrot was removed.
Observation on 02/18/2025 at 1:43 PM showed a sign above Resident 61's bed informing staff that the resident's previous sheepskin palm protector was discontinued and to now use the Therapy Carrot.
There was no Therapy Carrot observed in place.
505519
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505519 B.
Wing 02/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Benson Heights Rehabilitation Center 22410 Benson Road SE Kent, WA 98031