Bent County Healthcare Center

In the surveyor’s words

From the most serious findings on record at Bent County Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 24, 2023

  Based on observations, record review and interviews, the facility failed to ensure one (#105) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. During the 4/28/23 visit, the surgeon removed the sutures and staples from the surgical site on both sides of the right ankle. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. […]

• Actual harm, isolatedF686Aug 24, 2023

  Based on observations, record review and interviews, the facility failed to ensure for one (#1) of two residents reviewed for pressure injuries received care consistent with professional standards of practice. Resident #105 had surgery on her right ankle on 4/11/23. She returned to the facility with orders from the surgeon to leave the dressings intact until the follow up visit. The resident went to the surgeon for the follow-up visit on 4/28/23. The surgeon's note included the right foot was non weight bearing and for the facility to keep soft and padded around the ankle. The orders also noted to keep the boot on except for baths. The resident had complaints of pain to the right lower extremity on 5/11/23. […]

• Actual harm, isolatedF689Mar 10, 2021

  Based on observations, record review and interviews, the facility failed to ensure assistance, supervision, and an environment free of accident hazards for one (#27) of five sample residents out of 25 sample residents. The facility failures to observe, supervise, anticipate the needs and implement appropriate person centered fall prevention measures for Resident #27, who had a [DIAGNOSES REDACTED].#27's fall. Resident #27 was found on the floor on 1/16/2021 at 11:40 p.m. Resident #27 had an unwitnessed fall and sustained two lacerations to the left side of her head, requiring sutures, and a dislocated shoulder. […]

• No harm, potential for more than minimal, widespreadF812May 1, 2025

  Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, entrance to the dish room and the dish receiving room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Floors policy, revised December 2009, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:51 a.m. The policy revealed all floors should be mopped, cleaned and or vacuumed daily in accordance with the facility's established procedures. The environmental services director (ESD) maintained floor-cleaning procedures. […]

• No harm, potential for more than minimal, widespreadF925Sep 19, 2024

  Based on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and cockroaches, in one of one kitchen and one of two dining rooms. Specifically, the facility failed to: -Ensure an effective pest control program that eliminated the presence of live and dead cockroaches in the kitchen and dining room, food preparation area, storage area, serving and eating areas; -Ensure dead and decaying roaches were removed from the dining room lower cupboard space; and, -Ensure heavily occupied sticky pest traps, containing a large amount of trapped dead and decaying cockroaches were removed timely and when the traps were full. Findings include: I. […]