Bennington Glen: Medications Crushed Despite Do-Not-Crush List - OH
All four.
The nurse, identified in the inspection report as LPN #89, was observed at 8:00 a.m. crushing Tylenol eight-hour arthritis pain extended-release tablets, two separate doses of Metoprolol Succinate extended-release tablets, and Pantoprazole Sodium delayed-release tablets before mixing them into pudding and giving them to Resident #68. When inspectors asked about it, LPN #89 confirmed she had done exactly that.
Resident #68 had been a resident at Bennington Glen since September 2018. The resident's diagnoses included paroxysmal atrial fibrillation, a heart rhythm condition; polyosteoarthritis; and gastroesophageal reflux disease. The Metoprolol Succinate, prescribed in two tablets totaling 75 milligrams daily, was treating the resident's high blood pressure. The Pantoprazole was for the GERD. The Tylenol, at 650 milligrams twice a day, was managing arthritis pain.
Each of those drugs had been formulated specifically to release into the body slowly, over hours. Extended-release and delayed-release coatings are not incidental to how a drug works. They are the mechanism. Crushing them destroys that mechanism, releasing the full dose at once rather than gradually.
A physician order in the resident's chart, dated November 2021, addressed exactly this situation. Nursing staff were permitted to crush medications and mix them in food or drink, the order said, unless the medication was delayed-release, extended-release, enteric coated, or on the do-not-crush list. Resident #68's four medications met multiple conditions on that list of exceptions. The Tylenol was extended-release. The Metoprolol tablets, both the 25-milligram and 50-milligram doses, were extended-release. The Pantoprazole was delayed-release.
The facility's own do-not-crush list named all four.
Inspectors counted the medication errors across 34 administration opportunities observed during the visit. There were four errors, all involving Resident #68, all on that same morning. That produced an error rate of 11.76 percent. The threshold for compliance is five percent.
One resident. One nurse. One morning. Enough to more than double the permissible error rate for the entire observation period.
The inspection was conducted as a complaint survey, completed April 27, 2026. The facility, located at 825 State Route 61 in Marengo, had a census of 68 residents at the time.
What the report does not say is whether anyone checked on Resident #68 after the medications were administered, or whether the resident experienced any effects from receiving four crushed extended-release and delayed-release drugs at once. It does not say how long LPN #89 had been assigned to this resident, or whether this had happened before. It does not say who filed the complaint that triggered the inspection.
What it does say is that LPN #89 confirmed crushing the medications when asked. No dispute, no confusion about what had occurred. The nurse knew what she had done. The facility's own paperwork said not to do it. The resident's physician order said not to do it.
Resident #68 has lived at Bennington Glen for more than seven years.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bennington Glen Nursing & Rehabilitation Center from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
BENNINGTON GLEN NURSING & REHABILITATION CENTER in MARENGO, OH was cited for violations during a health inspection on April 27, 2026.
The nurse, identified in the inspection report as LPN #89, was observed at 8:00 a.m.
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.