Bentwood Nursing & Rehab: Feeding Tube Care Failures - MO
Inspectors visited on November 17, 2025, responding to a complaint. They cited two deficiencies total. One of them, filed under the regulatory category covering quality of life and care, addressed feeding tubes specifically — whether they were medically justified, and whether residents had consented to having them.
The citation was rated scope and severity level D, meaning inspectors identified the problem as isolated and found no actual harm had occurred. But they concluded there was potential for more than minimal harm. That distinction matters. A feeding tube runs directly into a person's stomach or intestine. Improper care can cause infection at the insertion site, aspiration, internal injury, or worse. And a tube placed without genuine informed consent is not simply a paperwork problem.
Consent for a feeding tube is not a formality. For a nursing home resident, many of whom have dementia, difficulty communicating, or diminished capacity to make decisions, the question of who agreed to a tube — and whether they truly understood what they were agreeing to — sits at the center of basic dignity in care. Inspectors found Bentwood had fallen short of the standard required in this area.
The facility reported a correction date of December 17, 2025, one month after the inspection.
What changed between November 17 and December 17 is not described in the inspection record. Whether the resident at the center of the complaint received a different standard of care in the weeks before the correction date was reported, the record does not say. Whether family members were notified, whether a care conference was held, whether the tube in question was reviewed by a physician — none of that appears in what inspectors documented.
Bentwood Nursing and Rehab sits in Florissant, a suburb north of St. Louis. Complaint inspections are triggered by reports filed with state or federal health agencies, typically by residents, family members, or staff. The inspection record does not identify who filed the complaint that brought inspectors to the facility in November, or what specific circumstances prompted it.
The second deficiency cited during the same inspection is not detailed in the available record.
A level D citation, the lowest rung on the severity scale, can create a misleading impression of minor consequences. But feeding tube care failures have caused serious harm at nursing facilities across the country. Tubes become dislodged. Insertion sites become infected. Residents who cannot speak for themselves cannot report that something feels wrong. The gap between "no actual harm documented" and "no harm occurred" is not always visible in an inspection report.
The one-month correction window the facility set for itself is standard. Whether the underlying problem — inadequate attention to medical justification, insufficient documentation of consent, or gaps in the physical care of the tube itself — was genuinely resolved by mid-December, or whether the paperwork simply caught up, is a question the inspection record cannot answer.
For the resident at the center of this complaint, the inspection was completed and the file was closed. Whether they had ever been asked, clearly and in terms they could understand, whether they wanted a tube delivering nutrition directly into their body — that question was somewhere in the paperwork Bentwood was told to fix.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
BENTWOOD NURSING & REHAB in FLORISSANT, MO was cited for violations during a health inspection on November 17, 2025.
Inspectors visited on November 17, 2025, responding to a complaint.
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.