Health inspection·April 24, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 5 residents (Resident #1) reviewed for shower documentation. The facility failed to ensure documentation reflected Resident #1 received showers as scheduled and desired. This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. Findings Included: Record review of Resident #1's Face Sheet dated 4-24-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Sequelae (a condition which is the consequence of a previous disease or injury) following nontraumatic subarachnoid hemorrhage (bleeding into the space between the brain and the thin tissues that cover it causing long-term or permanent neurological, cognitive, or physical consequences) and secondary diagnoses of anxiety disorder, unspecified dementia (a decline in mental ability severe enough to interfere with daily life), Hypokalemia (abnormally low levels of potassium in the blood), and lack of coordination. Record review of Resident #1's Nursing Home PPS (NP) Item set (this is the initial 5-day assessment used to bill for Medicare Part A) MDS assessment dated [DATE] revealed a BIMS Score of 7 indicating severe cognitive impairment. Resident #1's Functional Abilities of the MDS indicated Resident #1 needed partial assistance (where the helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs in bathing or showering). Record review of the facility's shower log on 4-24-2025 at 3:00 PM, indicated no shower sheets were filled out for Resident #1 from 4-3-2025 through 4-11-2025 (a 9-day period) and from 4-13-2025 through 4-15-2025 (a 3-day period). Record review of the facility's electronic medical record bathing log corroborated this finding. There were also no indications in the shower log or electronic medical record that Resident #1 ever refused a shower. In an interview with the DON on 4-24-2025 at 10:30 AM she disclosed the facility keeps track of resident's showers by keeping shower sheets in on large binder for the entire facility. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675906 Printed: 05/15/2026 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 675906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 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)