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Complaint Investigation

Bentwood Nursing & Rehab

Inspection Date: November 17, 2025
Total Violations 2
Facility ID 265757
Location FLORISSANT, MO
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Inspection Findings

F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

evaluation was not kept in the resident's EMR, the neurological evaluations were only available upon request that were kept in a filing cabinet behind the nurse's station. Observation and interview on 10/21/25 at 11:50 A.M., showed the resident laid in bed on top of a Hoyer sling with the bed approximately 4 feet from the ground. The resident was not wearing a fall bracelet. The resident's call light laid on the floor between the bed and the wall. The resident said he/she was unable to reach the call light and would yell out if he/she needed anything. Observation on 10/22/25 at 7:15 A.M., showed the resident sat in his/her room

in a wheelchair. The wheelchair had no roll bars on the back of wheelchair. The resident's call light laid on

the floor between the bed and the wall. During an interview on 10/21/25 at 10:15 A.M., CNA D said the residents who are a fall risk are identified by a fall risk bracelet. CNA D said those residents with the bracelet should have their beds in low position and have a floor mat. During an interview on 10/21/25 at 3:45 P.M., the Director of Nursing (DON) said she expected staff to follow the facility's Fall Management Policy and Accident and Incident Documentation and Investigation policy. The DON expected the medical records to accurately reflect the residents' plan of care consistently and accurately documented across the care plan, physician orders and progress notes. During an interview on 10/22/25 at 11:40 P.M., Licensed Practical Nurse (LPN) J said residents who are high risk will have fall mats, low beds and pillow wedges.

The residents who are high fall risk will have their wheelchairs locked and are kept at the nurses' station or

in a common area to keep them safe. Staff know who is high risk because the resident wears a high risk bracelet and is noted in the resident's care plan. During an interview on 10/22/25 at 1:40 P.M., the MDS Coordinator said after every resident fall, the resident's intervention(s) are placed on the individuals care plan. The MDS Coordinator expected interventions such as floor mats, low bed, anti-roll backets be reflected on a resident's care plan. During an interview on 10/22/25 at 2:45 P.M., the Administrator said she expected staff to follow the facility's Fall Management Policy and Accident and Incident Documentation and Investigation policy. 2636245

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bentwood Nursing & Rehab

1501 Charbonier Road Florissant, MO 63031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0693

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited BENTWOOD NURSING & REHAB in FLORISSANT, MO for a deficiency under regulatory tag F-F0693 during a complaint investigation conducted on 2025-11-17.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of BENTWOOD NURSING & REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-17.

📋 Inspection Summary

BENTWOOD NURSING & REHAB in FLORISSANT, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLORISSANT, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BENTWOOD NURSING & REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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