Bennington Glen Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bennington Glen Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 27, 2026

  Based on medical record review, review of the facility's investigation, staff interviews, and policy review, the facility failed to ensure Resident #6 received adequate supervision and assistance with toileting to prevent the resident from falling. Actual Harm occurred on 03/21/26 when Resident #6 was not adequately supervised in the bathroom, was left on the toilet while Certified Nurse Aide (CNA) #41 went to get new bedding and an adult brief, and Resident #6 got herself off the toilet and was coming out of the door when CNA #41 came in and saw Resident #6 fall backwards hitting her back and head on the sink, sustaining serious physical harm and injuries and was subsequently hospitalized related to rib fractures to her left seven through eleventh left ribs, a small left hemopneumothorax… […]

• No harm, potential for more than minimal, patternF638Oct 24, 2024

  Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) 3.0 assessments were completed timely and as required. This affected nine residents (#14, #15, #23, #27, #30, #47, #52, #56, and #60) of 36 residents reviewed for resident assessments. The facility census was 74. Findings include 1. Review of Resident #14's medical record revealed an admitted [DATE]. Diagnoses included dementia. Review of Resident #14's MDS assessments revealed a quarterly assessment dated [DATE] was in progress. Resident #14's prior quarterly assessment was dated 06/01/24. The resident's MDS tab in her electronic medical record indicated the assessment was overdue. An interview on 10/22/24 at 2:54 P.M. […]

• No harm, potential for more than minimal, patternF805Oct 24, 2024

  Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving residents on a pureed diet. This had the potential to affect five residents (Residents #4, #19, #29, #34, #172) who were on a prescribed pureed diet. The facility census was 74. Findings include: Interview on 10/22/24 at 10:03 A.M. with Dietary [NAME] (DC) #344 stated she wanted the puree textures at a mashed potato consistency. DC #344 stated when the puree texture was complete, it was like baby food, which was smooth with no chunks. DC #344 said she tastes her puree food, and a resident should not have to chew a puree food item. DC #344 said there were six residents on a puree diet. […]

• No harm, potential for more than minimal, patternF880Oct 24, 2024

  Based on observations, policy review, review of Centers for Disease Control and Prevention (CDC) guidance, medical record review, and resident and staff interviews, the facility failed to properly do contact tracing or implement broad-based testing when staff and residents tested positive for COVID-19. The facility also failed to offer Resident #3 another room (if available) when roommate tested positive for COVID-19, and Resident #3 was not tested in a timely manner while exhibiting symptoms of COVID-19. This affected 14 Residents (#3, #6, #22, #23, #33, #35, #60, #63, #121, #171, #173, #279, #280, and #500). The facility census was 74 residents. Findings include: Review of the facility COVID-19 tracking information revealed the following positive COVID-20 cases in 27 days. […]

• No harm, potential for more than minimal, patternF881Oct 24, 2024

  Based on record review, staff interview, review of infection control logs, and policy review, the facility failed to implement their antibiotic stewardship program policy and thoroughly track infections to ensure infections and antibiotics were ordered appropriately. This affected 13 (#22, #27, #37, #39, #42, #54, #57, #173, #174, #175, #176, #177, and #273) of 17 residents identified as ordered antibiotics during September 2024 and October 2024. The facility census was 74. Findings include: 1. Review of the Infection Control Log dated for September 2024 revealed the facility tracked residents that had received antibiotics for the month of September 2024. […]