Bentleys Extended Care

In the surveyor’s words

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

• Immediate jeopardy, patternF656Jun 30, 2023

  Based on interviews, record review, observations, and facility policy review, the facility failed to ensure resident-centered comprehensive care plans were developed, implemented, and revised to meet the needs of 13 (Residents #10, #96, #17, #44, #8, #14, #145, #2, #36, #30, #27, #35, and #29) of 29 residents reviewed for comprehensive care plans. The facility failed to develop and implement comprehensive care plans to address residents at risk for falls and residents with a history of multiple falls with injury. […]

• Immediate jeopardy, patternF689Jun 30, 2023

  Based on observations, interviews, and record review, the facility failed to determine causative factors of resident falls, implement and evaluate interventions to prevent falls, and develop an effective communication system that identified residents at risk for falls and provided care staff with interventions to prevent more falls for 4 (Residents #10, #8, #145, #96 and #14) of 4 residents reviewed for falls. Specifically, the facility failed to: - Determine causal factors and implement new interventions following multiple falls for Resident #10 that resulted in a fractured right hip. […]

• Immediate jeopardy, patternF700Jun 30, 2023

  Based on observations, interviews, record review, the facility failed to assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on resident beds for 2 (Resident #96 and Resident #10) of 7 residents reviewed for side rail use. Resident #96 stated the side rails were barriers, made her feel confined and stranded, and she had a fear of not being able to get out of bed because of them- causing her to not want to get into her bed to sleep at night. As a result she fell asleep in her chair, fell forward and obtained a large hematoma on the right side of her forehead. […]

• Immediate jeopardy, isolatedF600Feb 4, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse when an allegation of physical abuse was made for one resident (Resident #1). On 2/1/25 at approximately 10:00 A.M., Registered Nurse (RN) A heard banging on the wall inside the resident's room, and someone yelling, Stop that, stop that, do it again, then a loud slap inside the resident's room and when he/she opened the resident's door he/she saw Certified Nurse Aide (CNA) B holding the resident against the wall. RN A notified the Director of Nurses (DON) of an allegation of abuse and the DON directed RN A not to send CNA B home. CNA B remained in the facility providing care to other residents for over five hours after the allegation was reported. […]

• Actual harm, isolatedF600May 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) was free from physical abuse when Certified Nurse Aide (CNA) C covered and twisted the resident's mouth when he/she cried during a shower, which resulted in bruising to the resident's face. The sample was 3. The census was 49.Review of the facility's Abuse Prevention Program policy, undated, showed:-Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]