Bentwood Nursing & Rehab: Fall Safety Failures - MO
This is what inspectors found at Bentwood Nursing & Rehab on October 21, 2025.
The resident told inspectors he or she could not reach the call light and would simply yell out if help was needed.
The next morning, inspectors returned. The call light was still on the floor.
The resident was now sitting in a wheelchair in the room. The wheelchair had no anti-roll bars on the back.
Staff at Bentwood described, in consistent detail, exactly what should have been done differently. CNA D told inspectors that residents identified as fall risks are supposed to wear a fall risk bracelet, have their beds kept in the lowest position, and have a floor mat placed beside the bed. Licensed Practical Nurse J said high-risk residents get floor mats, low beds, and pillow wedges, and that their wheelchairs are supposed to be locked, with the residents kept at the nurses' station or in a common area where staff can watch them. The MDS Coordinator said that after every fall, new interventions are supposed to be added to the resident's care plan, and she expected those interventions, floor mats, low beds, anti-roll brackets, to be reflected there.
None of that matched what inspectors observed in this resident's room.
The Director of Nursing told inspectors she expected staff to follow the facility's fall management policy and that medical records should accurately reflect each resident's plan of care. The Administrator said the same thing: she expected staff to follow the policy.
What the policy required and what the resident experienced were two different things.
Inspectors also found that neurological evaluations for the resident were not stored in the electronic medical record. They were kept in a filing cabinet behind the nurses' station, available only if someone thought to ask for them.
The deficiency was cited under F0689, which covers the obligation to keep residents free from accidents the facility could reasonably prevent. CMS rated the harm level as minimal harm or potential for actual harm, with few residents affected.
A resident who cannot reach a call light, in a bed four feet off the ground, with no mat on the floor below, is one bad moment away from a serious fall. The yelling, the resident said, was the backup plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bentwood Nursing & Rehab from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
BENTWOOD NURSING & REHAB in FLORISSANT, MO was cited for violations during a health inspection on November 17, 2025.
This is what inspectors found at Bentwood Nursing & Rehab on October 21, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.