A list of the most recent deficiencies for Bentleys Extended Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-30 | 2023-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-08-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-30 | 2023-08-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-30 | 2023-07-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-30 | 2023-07-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-30 | 2023-07-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-30 | 2023-07-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-30 | 2023-07-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-30 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-07-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-30 | 2023-07-28 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-30 | 2023-07-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-30 | 2023-07-28 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-06-30 | 2023-07-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-30 | 2023-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-30 | 2023-07-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-30 | 2023-07-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-30 | 2023-07-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-30 | 2023-07-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-30 | 2023-07-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-06-30 | 2023-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-30 | 2023-07-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-30 | 2023-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-30 | 2023-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-30 | 2023-07-13 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-06-30 | 2023-07-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-30 | 2023-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-30 | 2023-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-30 | 2023-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-30 | 2023-06-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-30 | 2023-06-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-30 | 2023-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-30 | 2023-06-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-30 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-11-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-11 | 2021-09-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-11 | 2021-09-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-07 | 2019-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-07 | 2019-12-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-07 | 2019-12-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-07 | 2019-12-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-07 | 2019-12-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-11-07 | 2019-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-07 | 2019-12-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-07 | 2019-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-07 | 2019-12-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-07 | 2019-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-07 | 2019-11-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-07 | 2019-11-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-30 | 2019-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-30 | 2019-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-30 | 2019-03-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-30 | 2019-03-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-30 | 2019-03-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-01-30 | 2019-03-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-30 | 2019-03-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-30 | 2019-03-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-01-30 | 2019-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-30 | 2019-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-30 | 2019-03-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-01-30 | 2019-03-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-30 | 2019-03-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-30 | 2019-03-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-01-30 | 2019-03-10 | N |
