Bentwood Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Bentwood Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one resident (Resident #3) when staff failed to evacuate a bed ridden resident from a room that was on fire. On [DATE] at approximately 12:30 A.M., a fire occurred in the resident's room. Staff responded to the room, but were unable to remove the resident from the room. Staff interviewed said the bed did not fit through the doorway and there was insufficient number of staff who responded to the room with the fire to remove the resident from the bed. In addition, staff in the facility failed to follow their fire plan by not responding appropriately to the fire alarm. […]

• Immediate jeopardy, patternF678May 6, 2022

  Based on observation, interview and record review, the facility failed to ensure staff were able to provide emergency basic life support immediately when needed, including cardio-pulmonary resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to restore spontaneous blood circulation and breathing in a person in [CONDITION(S)]), to any resident requiring such care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to have a system to ensure residents' code statuses are obtained timely upon admission, updated when changed and documented congruently through the medical record. […]

• Immediate jeopardy, isolatedF678Feb 2, 2024

  Based on interview and record review, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) in a timely manner for one of seven sampled residents who was a full code (all life saving measures to be performed) and found by staff without a pulse (Resident #1). Additionally, not all direct care staff were aware of the location of the code status documentation in residents' records (Residents #2 and #3). […]

• Immediate jeopardy, isolatedF908Dec 20, 2022

  Based on observation, interview and record review, the facility failed to maintain equipment in safe operating condition. On 11/18/22 at approximately 11:00 A.M., two staff noticed they could not turn down the packaged terminal air conditioner (PTAC) unit in a resident room (Resident #3 and Resident #10). The staff did not report the problem to maintenance staff. On 11/19/22 at approximately 12:30 A.M., a fire occurred in the residents' room. Review of the facility's investigation summary showed they determined the cause of the fire was the PTAC unit. Review of the fire marshal investigation showed the final hypothesis on the origin of the fire was the lower right side of the PTAC unit in the residents' room. […]

• Immediate jeopardy, isolatedF600Jun 30, 2022

  Based on interview and record review, the facility failed to ensure all residents were free from mental and verbal abuse when one staff member, Certified Nursing Assistant (CNA) KK, cursed at and threatened physical violence against one resident (Resident #605). The staff member used profanity, made verbal threats, and used threatening gestures toward the resident. When the charge nurse was made aware, he/she failed to promptly notify administration per facility policy. Additionally, the facility failed to follow it's policy for protection of residents by failing to immediately suspend the employee after the allegation of abuse was made. […]