Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benson Heights Rehabilitation Center during CMS and state inspections, most recent first.
The facility's kitchen failed to maintain sanitary conditions, as observed by the lack of logs for sanitizing solution concentration and refrigerator temperatures. Additionally, improper handling of paper towels and inadequate cleaning practices were noted during lunch preparations, posing a risk of contamination.
The facility failed to provide proper written transfer notifications to residents and their representatives, as evidenced by four cases where forms were either improperly signed or missing. This deficiency involved residents being transferred to hospitals without receiving the necessary documentation to inform them of their rights and appeal procedures.
The facility failed to obtain informed consent for the use of bed rails and bed placement against walls for three residents, despite their medical conditions and care plans indicating the need for such arrangements. Staff E confirmed that consent was not obtained, which is necessary to ensure residents are informed and involved in their care decisions.
The facility failed to complete Level II PASRR evaluations for four residents, including those with severe memory impairment, depression, schizophrenia, PTSD, and significant behavioral issues. Despite indications from Level I screenings, the necessary evaluations were not documented, placing residents at risk for unmet mental health care needs. The Social Services Director acknowledged the oversight and the importance of these evaluations.
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs. A resident on anticonvulsant medication lacked a care plan for its use, while another with a urinary catheter and pressure ulcers did not have individualized Enhanced Barrier Precautions. Three residents had beds against the wall without documentation, and a resident with hearing difficulties lacked a care plan for communication. Additionally, a resident's care plan for seizure medication and antibiotics lacked monitoring details.
The facility failed to obtain and implement physician orders for several residents, leading to potential risks and unmet needs. A resident's bed was placed against the wall without a physician order, and another resident's oxygen tubing was not changed weekly as required. Conflicting orders for a pain medication patch lacked clarity, and a swallow evaluation for a resident at risk of aspiration was delayed. These deficiencies compromised resident safety and care quality.
The facility failed to implement skin breakdown interventions for a resident with severe memory impairment by not using a Therapy Carrot as ordered, and lacked documentation for its application. Additionally, another resident with heart failure and edema was not monitored daily for weight as required, with only weekly checks being conducted, despite the presence of pitting edema.
The facility failed to conduct safety assessments for three residents with beds against the wall, did not secure hazardous materials in an unlocked utility room, and inadequately supervised a resident with a history of PTSD and substance abuse during a leave of absence. The resident left unaccompanied despite a physician order requiring accompaniment, and the care plan lacked necessary interventions.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. One resident with respiratory failure was not monitored according to physician's orders, with low oxygen levels not reported or documented. Another resident's oxygen tubing was not changed weekly as required, increasing infection risk.
The facility failed to provide appropriate pain management for two residents. One resident received incorrect dosages of PRN pain medication, leading to inadequate pain relief. Another resident, on a scheduled pain regimen, was not monitored for side effects despite complaints of sedation. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to prescribed medication parameters and monitoring protocols.
The facility failed to provide necessary social services for two residents with pressure ulcers, leading to a deficiency in care. One resident, with dementia and muscle weakness, refused care, including repositioning, contributing to worsening skin conditions and weight loss. The social services department was unaware of these refusals. Another resident also refused care, and their care plan did not involve social workers, contributing to continued resistance. The DON acknowledged the challenges but did not indicate effective measures to address refusals.
A resident received an antibiotic for 23 days instead of the prescribed 14 days due to a transcription error by the Unit Manager, leading to unnecessary medication administration. The resident, who required a CPAP machine, was at risk of adverse side effects from the prolonged antibiotic use.
A facility failed to provide a resident with the required carbohydrate-controlled, renal diet, despite the resident's complex medical conditions. The Dining Services Director was unaware of the dietary order and struggled to provide the necessary menus, leading to the resident receiving meals that did not meet their nutritional needs. The dietician emphasized the importance of following the correct menus, which were not adhered to by the dietary staff.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food and drinks served to residents were prepared and distributed under sanitary conditions. During an inspection of the facility kitchen, it was observed that there was no log documenting that the kitchen's sanitizing solution was at an effective concentration. Staff S, the Dining Services Director, was unable to locate the log and confirmed that the sanitizer had not been checked since the shift change over three hours prior. Additionally, the refrigerator logs showed that temperatures had not been recorded for two consecutive days, indicating a lapse in monitoring the refrigeration conditions. Further observations during lunch preparations revealed that the paper towel dispenser was empty, and a roll of paper towels was placed on the counter, with the loose part resting against a can opener. The roll was dotted with drips of water, suggesting improper handling. Staff U, a Dietary Aide, used a piece of paper towel from the roll to wipe down a cart without using sanitizer or washing hands before or after the task, and then returned to food preparation. Staff S acknowledged that the paper towel dispenser should have been refilled and that sanitizer should be used for cleaning surfaces, with gloves only used when handling ready-to-eat foods.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as evidenced by the cases of four residents. Resident 22 was discharged to an acute care hospital without a properly signed transfer notification form, as it only contained the signature of a registered nurse and not the resident's or a witness's signature. The unit manager confirmed that the notification should have been witnessed and provided to the resident or their representative to ensure understanding of their rights. Similarly, Resident 63 was discharged without a properly signed transfer notification form, which only had the staff's signature and not the resident's or representative's. The staff involved believed that the social service staff was responsible for sending the notice to the representative, indicating a lack of clarity in the process. Resident 82's case was further complicated by the absence of a written transfer notification in the health records, with staff unable to locate it in the medical records or scanning bin. The social service director emphasized the importance of providing a written copy to inform residents or representatives about their rights and appeal procedures. Resident 20, who had no memory impairment and a history of medical issues, was transferred to the hospital twice without proper written notifications. Both instances lacked the resident's signature and a witness signature, with only the staff's signature present. The facility administrator stated that nurses were responsible for completing the notification form, while social services were tasked with ensuring the form was provided to the resident or their representative. This deficiency highlights a systemic issue in the facility's process for handling transfer notifications.
Failure to Obtain Informed Consent for Bed Rail and Bed Placement
Penalty
Summary
The facility failed to ensure that residents were provided informed consent for the use of bed rails and the placement of beds against walls, affecting three residents. Resident 63, who had no memory impairment and was diagnosed with general muscle weakness and mobility issues, had a bed rail installed without consent. The care plan indicated the use of an assist rail for bed mobility, but consent was not obtained, as confirmed by Staff E, the Unit Manager. Similarly, Resident 4, who had no memory impairment and was diagnosed with morbid obesity and a history of stroke, had their bed placed against the wall without consent. The care plan did not identify this arrangement, and Staff E acknowledged the oversight. Resident 70, diagnosed with lack of coordination and general muscle weakness, also had their bed placed against the wall without consent, which was not documented in their care plan. Staff E confirmed that consent should have been obtained for these arrangements to ensure residents were informed and involved in their care decisions.
Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASRR) evaluations were completed and incorporated into the care plans for four residents who required them. Resident 61, who was admitted with severe memory impairment and multiple mental health diagnoses, had three Level I PASRR screenings indicating the need for Level II services, but no Level II evaluation was on file. Similarly, Resident 22, diagnosed with depression and schizophrenia, had a Level I PASRR indicating the need for a Level II evaluation, but no such evaluation was documented. Staff D, the Social Services Director, acknowledged the absence of these evaluations and noted the importance of obtaining consultant recommendations for mental health care. Resident 82, with diagnoses including depression and PTSD, also required a Level II PASRR as indicated by a Level I screening, but no documentation of the evaluation was found. Resident 20, who exhibited significant behavioral issues, had a Level I PASRR indicating the need for a Level II evaluation, but this was not completed due to the resident's frequent discharges and admissions. Staff D stated that the hospital should have completed the referral before admission and emphasized the importance of the Level II PASRR in determining the necessary level of care. The lack of completed Level II evaluations for these residents placed them at risk for unmet mental health care needs.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, leading to potential risks for unmet care needs and negative health outcomes. Resident 34, who had a history of stroke and was on anticonvulsant medication for a seizure disorder, did not have a care plan addressing the use of this medication. The Director of Nursing acknowledged the oversight, noting that a care plan should have been developed to address the anticonvulsant use. Resident 10, diagnosed with difficulty voiding urine and dementia, had a urinary catheter and multiple pressure ulcers. However, the care plan did not reflect the need for Enhanced Barrier Precautions specific to the resident's condition, such as the presence of pressure ulcers and catheter use. The Director of Nursing confirmed that the care plan needed to be individualized to address these specific needs. Residents 4, 63, and 70 had their beds positioned against the wall for safety, but there were no care plans documenting this arrangement. Additionally, Resident 70, who had difficulty hearing, did not have a care plan addressing their hearing impairment. Resident 38's care plan for seizure medication lacked details on monitoring for side effects and drug toxicity, and their antibiotic treatment for respiratory illness was not adequately documented in the care plan. The Unit Manager and Director of Nursing both acknowledged these deficiencies, emphasizing the importance of including medication monitoring in the care plans.
Failure to Obtain and Implement Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were obtained, clarified, and implemented for several residents, leading to potential risks and unmet needs. For Resident 4, the right side of the bed was placed against the wall without a physician order, which was acknowledged by Staff E as necessary to ensure an appropriate plan of care. Similarly, Resident 22's left side of the bed was against the wall without a physician order, and their oxygen tubing was not changed weekly as per facility policy due to the absence of a physician order. Staff F confirmed the importance of having these orders to prevent infection and ensure a physician-guided plan of care. Resident 63 also had their bed placed against the wall without a physician order, which Staff E noted was important for ensuring an appropriate care plan. Resident 71's bed was similarly positioned without a physician order, and Staff E reiterated the need for such an order. Additionally, Resident 34 had conflicting physician orders for a pain medication patch, lacking clarity on the strength of the medication, which Staff B stated should have been clarified. Resident 38, who had a history of stroke and difficulty swallowing, required a swallow evaluation due to the risk of aspiration. Although a physician order for the evaluation was made, it was not completed within the expected timeframe. Staff F and Staff B acknowledged the delay and the need for specific feeding instructions in the care plan, which were pending the evaluation. These deficiencies highlight the facility's failure to adhere to professional standards of practice, potentially compromising resident safety and care quality.
Failure to Implement Skin and Weight Monitoring Interventions
Penalty
Summary
The facility failed to implement skin breakdown interventions for Resident 61, who had severe memory impairment and required total assistance with daily routines. Despite a physician's order to use a Therapy Carrot for hand positioning to prevent skin breakdown, observations on multiple occasions revealed that the Therapy Carrot was not in place. Additionally, there was no documentation available for nursing staff to record the application and duration of the Therapy Carrot use, as confirmed by the Director of Nursing. This lack of documentation and implementation of the ordered intervention placed Resident 61 at risk for skin breakdown. The facility also failed to provide adequate weight monitoring for Resident 82, who had diagnoses of heart failure and edema and was receiving diuretic medication. The care plan required daily weight monitoring to manage edema and prevent complications such as cardiac overload. However, the Unit Manager admitted that Resident 82's weight was only being monitored weekly instead of daily. Observations confirmed the presence of pitting edema in Resident 82's lower extremities, indicating a failure to adhere to the care plan and monitor the resident's condition effectively.
Failure to Conduct Safety Assessments and Supervise Resident Leave
Penalty
Summary
The facility failed to ensure safety assessments were completed for three residents whose beds were placed against the wall. Resident 4, who had no memory impairment and diagnoses including morbid obesity and a history of stroke, did not have a safety assessment completed for their bed's right side against the wall. Similarly, Resident 63, with diagnoses of general muscle weakness and unsteadiness, and Resident 70, with lack of coordination and general muscle weakness, also lacked safety assessments for their beds placed against the wall. Staff interviews confirmed that these assessments were not conducted, which was necessary to ensure resident safety. Additionally, the facility did not secure hazardous materials in the North Utility Room, which was found unlocked with razors, hygiene supplies, and disinfectant cleaners stored in open cabinets. Staff acknowledged that the room should have been locked to prevent resident access to potentially dangerous items. This oversight posed a risk to resident safety, as these materials were accessible to vulnerable individuals. Furthermore, the facility failed to supervise a resident with a history of post-traumatic stress disorder and substance abuse during a leave of absence. Resident 90, who had a physician order requiring accompaniment when leaving the facility, left unaccompanied and admitted to misleading staff about having permission. The care plan did not include interventions for unaccompanied leave, and staff were unaware of the physician's order, which was potentially due to the resident's medical condition requiring a PICC line for antibiotic administration.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in oxygen administration and equipment maintenance. Resident 38, who had respiratory failure and low blood oxygen levels, was not monitored according to the physician's orders. Despite orders to monitor blood oxygen levels every shift and notify the provider of low levels, documentation showed that Resident 38's oxygen levels were at or below 90% on multiple occasions without any notification to the provider or adjustments to the care plan. Interviews with staff confirmed that the provider should have been notified, and the low oxygen levels should have been documented in the resident's progress notes. Resident 22, who had respiratory failure and chronic obstructive pulmonary disease, was dependent on supplemental oxygen. The facility's policy required weekly changes of oxygen tubing to prevent respiratory infections. However, observations revealed that Resident 22's oxygen tubing had not been changed according to this policy, as the tubing was dated beyond the weekly change requirement. Staff acknowledged the oversight and the importance of adhering to the policy to prevent infections.
Inadequate Pain Management and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in care. For one resident with a history of stroke and chronic nerve pain, the facility did not adhere to the prescribed parameters for administering PRN pain medication. On multiple occasions, the resident received incorrect dosages of pain medication, either too high or too low, based on their reported pain levels. This inconsistency in following the physician's orders resulted in the resident experiencing inadequate pain relief, as confirmed by the resident's own report of persistent pain and the staff's acknowledgment of the issue. Another resident, who was on a scheduled pain medication regimen for conditions such as low back pain and arthritis, was not monitored for side effects of the medication. Despite the resident's complaints of excessive sedation and observations of lethargy, there was no physician order to monitor for these side effects. Staff interviews confirmed the lack of monitoring and the importance of ensuring the resident was not experiencing adverse effects from the medication. These failures in pain management practices placed the residents at risk for untreated pain and potential medication side effects.
Failure to Provide Medically-Related Social Services for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide medically-related social services to two residents with pressure ulcers, leading to a deficiency in care. Resident 10, who had conditions such as dementia and muscle weakness, refused care on multiple occasions, including turning and repositioning, which are critical for pressure ulcer management. Despite having a care plan that involved both nurses and social workers to address these behaviors, the social services department was unaware of Resident 10's refusals. This lack of coordination and awareness contributed to the resident's worsening skin condition and significant weight loss. Similarly, Resident 21, who also had dementia and other health issues, refused care and repositioning, which are essential for preventing and managing pressure ulcers. The care plan for Resident 21 did not involve social workers in encouraging participation in care, which may have contributed to the resident's continued resistance to care. The Director of Nursing acknowledged the challenges posed by the residents' refusals but did not indicate any proactive measures taken to address these refusals effectively. The Social Services Director was aware of some behavioral issues but not the specific refusals of care, indicating a gap in communication and intervention strategies.
Antibiotic Administration Error for a Resident
Penalty
Summary
The facility failed to ensure that Resident 63's drug regimen was free from unnecessary medications, specifically concerning the administration of an antibiotic. Resident 63, who had no memory impairment and required a CPAP machine while sleeping, was prescribed a 14-day course of antibiotics for a sinus infection starting on January 15, 2025. However, due to a transcription error, the antibiotic was administered for a total of 23 days, exceeding the physician's order by nine days. The error occurred when Staff E, the Unit Manager, revised the antibiotic order on January 24, 2025, inadvertently restarting the 14-day course. This mistake led to the antibiotic being administered for an excessive duration. Staff C, the Infection Preventionist, confirmed that the antibiotic should have been given for only 14 days. The prolonged administration of the antibiotic placed Resident 63 at risk of experiencing avoidable adverse side effects and other potential negative health outcomes.
Failure to Provide Specialized Diets for Residents
Penalty
Summary
The facility failed to provide specialized diets required by residents, specifically for one resident who was assessed to need a carbohydrate-controlled, renal diet due to complex medical conditions including stage-3 kidney disease, diabetes mellitus, and morbid obesity. Despite the dietary order indicating the need for a specific diet, the resident expressed concerns about the facility not meeting their nutritional needs, citing an example of being served too many carbohydrates at breakfast. This indicates a lack of adherence to dietary requirements, which could lead to unmet nutritional needs and other negative health outcomes for the resident. The Dining Services Director, Staff S, was unable to provide the necessary therapeutic diet menus and was unaware of the resident's dietary order for a renal diet. During meal preparation, it was observed that the dietary staff did not have access to the correct menus, and the instructions provided did not specify the composition of meal trays for different dietary needs. Staff S took 44 minutes to access and print the required menus, and even then, the necessary food items, such as sliced carrots, were not available. The dietician, Staff T, confirmed the importance of following the break-out menus to ensure residents receive the nutrition they require, highlighting a significant lapse in the facility's dietary management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kent
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Skilled Nursing And Rehabilitation | 2.7 mi | — | 21 | 0 |
| Cedar River Healthcare Center | 3.2 mi | — | 1 | 0 |
| Puget Sound Transitional Care | 4.7 mi | — | 5 | 0 |
| North Auburn Care | 4.9 mi | — | 1 | 0 |
| Wesley Homes Des Moines Health Center | 5.6 mi | — | 24 | 0 |
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