Bentley Care Center

In the surveyor’s words

From the most serious findings on record at Bentley Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jun 23, 2022

  Based on record review, staff and resident representative interviews, the facility failed to honor documented advance directives and administered cardiopulmonary resuscitation (CPR) to 1 (Resident #500) of 3 sampled residents against the resident's expressed wishes. The facility failed to follow their policy and procedure regarding honoring residents' right for expressed advance directives. On [DATE] Resident #500 was readmitted to the facility. Resident #500 expressed wishes to not receive CPR if breathing or heart stopped. A Do Not Resuscitate Order (DNRO) was signed by the physician, and entered in the electronic clinical record. On [DATE] Resident #500 became unresponsive, had no pulse or respiration. […]

• Immediate jeopardy, isolatedF678Jun 23, 2022

  Based on record review, staff and resident representative interviews, the facility failed to withhold cardiopulmonary resuscitation (CPR) in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure nursing staff was properly trained to provide appropriate immediate care during a medical emergency in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] Resident #500 was readmitted to the facility. A Do Not Resuscitate Order (DNRO) was signed by the physician and entered in the electronic clinical record in accordance with Resident #500 expressed wishes to not receive CPR if breathing or heart stopped. On [DATE] Resident #500 became unresponsive, had no pulse or respiration. […]

• No harm, potential for more than minimal, widespreadF802Nov 21, 2024

  Based on interviews and record reviews, the facility failed to ensure that clinical nutritional assessments were completed within the scope of practice and failed to ensure appropriate competencies in accordance with standards of practice for 5 of 6 residents reviewed for nutrition (Residents #55, #6, #14, #43, and #26). This had the potential to affect 67 residents on the facility's current census. The findings included: A review of the Certified Dietary Manager (CDM) scope of practice dated March 2022 showed the following: Gather Nutrition Data. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based on observation, interview, and record review it was determined that the facility failed to store prepare, distribute, and serve food in accordance with professional standards for food service safety in the skilled nursing home kitchen, satellite serving kitchen, and the main campus kitchen, which potentially effected all of the 66 facility residents. The findings included: 1. During the initial kitchen/food service observation tour conducted on 11/18/24 at 9 AM and accompanied with the facility's Certified Dietary Manager (CDM). The following were noted: Observation of the walk-in refrigerator noted that the exterior fan covers (3) of the unit were soiled and dust ladened, and the surrounding ceiling area was also dust ladened. […]

• No harm, potential for more than minimal, widespreadF814Nov 21, 2024

  Based on observation, interview, and record review it was determined that the facility failed to dispose of garbage and refuse properly. The findings included: During the review of the facility's Policy Protocol - Waste, Recycling and Biohazard Management, the following were noted: Purpose - This policy establishes guidelines for disposal of regular trash, recycling material, hazardous and biohazard waste materials within the communities. Process - Comply with applicable laws and regulations and help protect employees, residents, and visitors from harm. #2: Hazardous and biohazard wastes are separated from common trash recycling to avoid creation of mixed wastes. […]