Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bentley Care Center during CMS and state inspections, most recent first.
The facility failed to ensure proper oversight in nutritional assessments, as the CDM conducted initial assessments for residents with complex conditions without review by a Registered Dietitian. This was outside the CDM's scope of practice and affected the care of multiple residents.
The facility failed to maintain food safety standards, with issues in storage, preparation, and sanitation affecting all residents. Observations included improperly thawed turkeys, contaminated thickener, worn cooking equipment, inadequate sanitizing chemical levels, and improper food temperatures. The preparation area was heavily soiled, and staff failed to wear beard restraints, risking contamination.
The facility failed to properly dispose of garbage and refuse, as observed in the main Garbage/Refuse Area. The area was littered with raw garbage, medical waste, and personal protective equipment, emitting a strong odor and attracting insects. The administrator noted that overflowing dumpsters and improper compaction by staff might be contributing factors.
The facility's Administrator failed to ensure proper oversight of dietary services, as the Consultant Dietitian did not review initial nutrition assessments completed by the CDM, which was outside her scope of practice. This affected six residents and had the potential to impact all 67 residents in the facility.
The facility failed to maintain resident privacy by posting signs with private medical information on room doors, affecting multiple residents. Signs indicated conditions like fall risk and oxygen caution. The DON was aware but unsure who placed the signs, noting some were inaccurate.
Two residents were addressed with terms like "honey" and "sweetie" by staff, which they found patronizing and disrespectful. One resident, with pneumonia and malnutrition, expressed discomfort with a nurse's and a nurse practitioner's behavior. Another resident, with a UTI and catheter, was addressed similarly by a CNA who viewed patients as family. These actions reflect a lack of sensitivity to resident dignity.
A facility failed to ensure an LPN met professional standards for IV medication administration, as the LPN lacked IV certification. The issue was discovered during a review of the LPN's personnel file, which lacked documentation of the required certification. The LPN administered Cefazolin via a PICC line to a resident with serious medical conditions, but resigned when asked to provide certification. Interviews with facility staff confirmed the absence of the certification and highlighted expectations for staff to perform duties within their scope of practice.
A resident with Parkinson's Disease and Dementia experienced difficulty eating independently due to tremors, as the facility failed to provide adaptive utensils and drinking cups. The resident's care plan lacked interventions for adaptive equipment, despite significant weight loss and a diagnosis of Dyskinesia. An Occupational Therapy screening recommended weighted utensils and adaptive drinking solutions to ensure safety and independence.
The facility failed to ensure accurate nutritional assessments and interventions for three residents, leading to deficiencies in their care. A resident on hemodialysis did not have their fluid needs adjusted according to restrictions, and another malnourished resident's supplement intake was not documented. A third resident, also malnourished, was not consistently provided with snacks, resulting in a caloric deficit.
A facility failed to transcribe a physician's order regarding a pharmacy recommendation for a psychotropic medication for a resident with severe cognitive impairment. The consultant pharmacist recommended discontinuing the PRN use of Chlordiazepoxide HCl, but the physician opted to continue its use for 90 days. This decision was not transcribed into the resident's record, leaving the original open-ended order without a stop date. The DON explained that the facility holds monthly GDR meetings to discuss medications, but the failure to update the resident's record led to a deficiency.
The facility failed to limit PRN orders for psychotropic drugs to 14 days for two residents, leading to unnecessary medication use. One resident had a PRN order for Ativan without a stop date, and another had a PRN order for Chlordiazepoxide extended for 90 days without proper documentation. The consultant pharmacist's review did not identify these issues, and the Director of Nursing acknowledged the oversight.
A resident on dialysis with a fluid restriction of 1260 ml daily was found with a full water pitcher in their room, contrary to physician orders and facility policy. Observations also revealed that the resident's breakfast tray contained more fluids than prescribed. Staff interviews highlighted a lack of communication and understanding of fluid restriction protocols, contributing to the deficiency.
A resident with a PICC line had their dressing changed daily instead of weekly as ordered, and the dressing lacked a date. Observations and interviews revealed inconsistencies in the dressing change schedule, with the resident and his wife noting only one change since admission. An LPN admitted to not checking the dressing date, highlighting a failure in maintaining accurate medical records and following physician orders.
An LPN failed to follow infection control practices during medication administration for a resident. The LPN did not wear gloves or perform hand hygiene between administering a nasal spray, injecting insulin, and giving oral medications, contrary to the facility's guidelines. The LPN believed gloves were unnecessary as there was no blood involved.
An inspection revealed that several resident bathrooms had inoperable nurse emergency call systems due to cords being wrapped around handrails and blocked by trash containers. This affected residents needing assistance with toileting.
Inadequate Oversight in Nutritional Assessments
Penalty
Summary
The facility failed to ensure that clinical nutritional assessments were completed within the appropriate scope of practice and competencies for five out of six residents reviewed for nutrition. The Certified Dietary Manager (CDM) conducted initial nutrition assessments for residents without oversight or review by a Registered Dietitian, which is outside the CDM's scope of practice. The CDM was responsible for estimating daily nutritional needs, including calories, protein, and fluids, for residents with complex medical conditions such as acute kidney failure, anemia, dysphagia, cerebral infarction, dementia, and protein-calorie malnutrition. The CDM, who has been working at the facility since 2001, stated that she was responsible for completing all initial nutrition assessments, including those for high-risk residents. She collected nutritional data and used a formulary provided by the consultant dietitian to estimate residents' nutritional needs. However, she was unaware of the specific dietary guidelines and standards of practice she should be using, and she did not know her scope of practice regarding nutritional assessments. The consultant dietitian confirmed that she did not review all initial assessments completed by the CDM and only saw them during quarterly assessments. The report highlights specific cases where the CDM completed initial assessments without proper oversight. For instance, a resident with severe protein-calorie malnutrition was assessed by the CDM, who estimated their nutritional needs without review by a dietitian. This lack of oversight and adherence to professional standards of practice had the potential to affect the nutritional care of 67 residents in the facility's current census.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting all 66 residents. During an inspection, several deficiencies were noted in the kitchen and food storage areas. The walk-in refrigerator had soiled and dust-laden fan covers and ceiling areas. Thawed turkeys were stored beyond the regulatory limit of 72 hours, and a powdered thickener was contaminated due to improper storage. Cooking skillets had worn Teflon surfaces, posing a contamination risk. Staff were observed drinking from open containers in the kitchen, risking contamination of clean surfaces and utensils. The sanitizing chemical levels in the 3-compartment sink and cleaning cloth buckets were below the required 150 PPM, and the dish machine hood and surrounding areas were rust-laden and moldy. Floor drains and the walk-in refrigerator floor were soiled with dried food matter and trash. In the satellite serving kitchen, cold food temperatures were not maintained at the required 41 degrees F, with chicken and turkey sandwiches recorded at 52 and 51 degrees F, respectively. This was confirmed with the Certified Dietary Manager. Additionally, the preparation area for soups was heavily soiled, with black carbon build-up on ovens and dried food matter on surfaces. A homemade beef base was improperly stored, with the kettle turned off overnight, failing to maintain the required holding temperature of 135 degrees F. A wire brush used for cleaning was worn, with wires potentially contaminating food. The walk-in freezer had a thick layer of ice build-up, with ice penetrating food containers, leading to freezer burn and contamination. Foods were improperly stored, with some directly on the floor and others on soiled wooden pallets. Freezer jackets were hung on food storage shelving, and preparation staff failed to wear beard restraints, risking hair contamination in food. These observations were documented with photographic evidence.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a tour of the main Garbage/Refuse Area. The area contained two commercial garbage/trash compactors and one open container for recyclables. The ground around these containers was covered with raw garbage, trash, medical personal protective equipment, medication containers, and medical waste products, making it difficult to walk around. The area emitted an offensive rotting garbage odor and was infested with flying insects. Numerous bags of garbage and trash were broken open and spilling contents before entering the compacting area, and the compactor itself was filled with open garbage, trash, and flying insects. The administrator suggested that the overflowing dumpsters and staff not ensuring proper compaction of garbage/trash bags before leaving the refuse area might be the reasons for the improper disposal. Additionally, the open container designated for recyclables was found to contain open garbage and trash bags. These observations were confirmed by the surveyor with the administrator after the tour.
Deficiency in Dietary Services Oversight
Penalty
Summary
The Administrator of the facility failed to ensure effective and efficient use of resources to maintain the highest practicable well-being of residents, specifically in the area of dietary services. The Consultant Clinical Dietitian did not provide dietary services, supervision, and oversight in accordance with State and Federal Guidelines. The Certified Dietary Manager (CDM) was completing initial nutrition assessments for residents, which was outside her scope of practice. This issue was identified for six residents reviewed for nutrition, with the potential to affect all 67 residents in the facility. The facility's Consultant Dietitian Agreement required regular visits to ensure compliance with regulations, but the Consultant Dietitian only visited the facility every two months and did not review initial nutrition assessments completed by the CDM. The Administrator was unaware that the Consultant Dietitian needed to complete these assessments and did not verify the CDM's scope of practice. Interviews revealed that the CDM had been completing initial nutrition assessments without oversight, and the Administrator did not address this in care meetings, leading to a deficiency in dietary services oversight.
Failure to Maintain Resident Privacy with Posted Medical Information
Penalty
Summary
The facility failed to maintain resident privacy by posting signs with private medical information on the entrance doors to their rooms. During an initial tour, a surveyor observed that 39 rooms had signs indicating various medical conditions and precautions such as fall risk, general caution, caution oxygen, swallow caution, sight impaired, hearing impaired, and no additional liquids. This affected 12 residents in the final sample and had the potential to affect 27 additional residents. Specific examples included signs for fall risk, hearing impairment, and oxygen caution, among others. An interview with the Director of Nurses (DON) revealed that she was aware of the issue and did not agree with the presence of these signs. She stated that she did not know who was responsible for placing the signs, suggesting it could be a certified nursing assistant or a nurse. The DON also mentioned that some signs did not even match the resident's actual condition, indicating a lack of accuracy and oversight in the process of posting these signs.
Failure to Respect Resident Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by the interactions with two residents. Resident #26, who was admitted with pneumonia and severe protein-calorie malnutrition, was observed being addressed as "honey" multiple times by a registered nurse during a routine check. The resident expressed discomfort with this form of address and also mentioned feeling patronized by a nurse practitioner who would get too close and pat her on the head. Despite her discomfort, the resident did not feel comfortable voicing her concerns directly to the staff. Similarly, Resident #18, who was admitted with a urinary tract infection and had an indwelling catheter, was addressed as "sweetie" by a certified nursing assistant during catheter care. The CNA, who has worked at the facility for several years, admitted to using such terms of endearment, explaining that she views her patients like family. These interactions demonstrate a lack of awareness and sensitivity to the residents' preferences and dignity, as confirmed by another staff member who acknowledged that such terms could be considered a dignity issue.
LPN Lacked IV Certification for PICC Line Administration
Penalty
Summary
The facility failed to ensure that the services provided by a Licensed Practical Nurse (LPN) met professional standards of quality, specifically in the administration of intravenous (IV) medication. The deficiency was identified during a review of the personnel file of an LPN, referred to as Staff B, who was responsible for administering IV therapy to a resident with a Peripherally Inserted Central Catheter (PICC). The review revealed that there was no IV certification on file for Staff B, which is a requirement according to the Florida Board of Nursing's standards for LPNs administering IV therapy. The incident involved Resident #264, who was admitted to the facility with serious medical conditions including acute and subacute infective endocarditis, bacteremia, and sepsis due to Methicillin Susceptible Staphylococcus Aureus. During an observation of a medication pass, Staff B was seen administering Cefazolin intravenously to the resident. Although the LPN followed proper procedures during the administration, the lack of documented IV certification raised concerns about the nurse's qualifications to perform such tasks. Interviews with the Director of Nursing and the Administrator confirmed that they were unable to provide the required IV certification for Staff B. The LPN resigned immediately when asked to provide the certification. The Director of Human Resources stated that while they ensure all licenses are current during the hiring process, they expect staff to perform duties within their scope of practice and alert appropriate personnel if there are any conflicts. However, the absence of the IV certification in the personnel file indicated a lapse in verifying the LPN's qualifications for administering IV therapy.
Failure to Provide Adaptive Eating Utensils for Resident with Parkinson's
Penalty
Summary
The facility failed to provide adaptive eating utensils and drinking cups to maintain the independence of a resident with Parkinson's Disease and Dementia. During a lunch meal observation, the resident was noted to have shaking and tremors, which caused difficulty in eating independently with regular silverware and drinking from a glass cup. The resident's clinical record indicated a significant weight loss and a lack of intervention for adaptive eating or drinking equipment in the care plan, despite the resident's diagnosis of Parkinson's Disease with Dyskinesia. The surveyor discussed the issue with the facility's administrator, who arranged for an Occupational Therapy screening. During the screening, the therapist only assessed the use of weighted utensils and did not include a weighted knife or adaptive drinking cups. The resident was able to eat some foods independently with the weighted utensils but continued to use a glass cup for drinking, posing a safety concern. The Occupational Therapy screening recommended the use of straws, a Sippy Cup, and weighted utensils to maintain the resident's safety and independence in self-feeding.
Nutritional Assessment and Intervention Deficiencies
Penalty
Summary
The facility failed to ensure accurate nutritional assessments and appropriate interventions for three residents, leading to deficiencies in their nutritional care. Resident #55, who was admitted with acute kidney failure and anemia, was on hemodialysis and had a fluid restriction order. However, the Certified Dietary Manager (CDM) did not adjust the resident's daily fluid needs to reflect the fluid restrictions, nor did they educate the resident on these restrictions. Additionally, the CDM failed to follow up with the dialysis dietitian to discuss a nutritional plan of care. Resident #6, diagnosed with dysphagia and cerebral infarction, was identified as malnourished. Despite being prescribed Boost supplements twice a day, the facility did not document the percentage of the supplement consumed daily. There were also missing data for meal intake on multiple days. The CDM acknowledged that the intake of supplements was not always recorded and that communication with nursing staff regarding the resident's intake was inconsistent. Resident #26, who was malnourished and had a BMI of 13, was not consistently provided with snacks as ordered. The resident expressed concern about the long intervals between meals and the lack of snacks unless requested. The CDM did not document follow-up on the resident's snack intake or supplement consumption, and there was no specific snack roster for residents. The CDM also failed to ensure that the resident's caloric intake met the estimated needs, resulting in a significant caloric deficit.
Failure to Transcribe Physician's Order for Psychotropic Medication
Penalty
Summary
The facility failed to transcribe a physician's order regarding a pharmacy recommendation for a psychotropic medication for one resident, leading to a deficiency in pharmaceutical services. The resident in question was admitted with diagnoses including dementia, anxiety, and depression, and had a severe cognitive impairment as indicated by a mental status score of 0. The consultant pharmacist recommended discontinuing the PRN use of Chlordiazepoxide HCl, but the physician decided to continue its use for 90 days, citing that the benefits outweighed the risks. However, this decision was not transcribed into the resident's record, leaving the original open-ended order without a stop date. During an interview, the Director of Nursing (DON) explained that the facility holds monthly gradual dose reduction (GDR) meetings to discuss medications and pharmacy recommendations. The attending physician is aware of these meetings but prefers the facility to discuss recommendations with the Psychiatric APRN. After these meetings, the DON informs the physician of recommended changes and takes telephone orders to enter into the resident's record. In this case, the failure to transcribe the physician's order following the pharmacist's recommendation resulted in a deficiency in the facility's pharmaceutical services.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days for two residents, leading to unnecessary medication use. Resident #53 was admitted with cerebral atherosclerosis exacerbation and vascular dementia and had a PRN order for Ativan without a stop date. Despite non-pharmacological interventions failing multiple times, the PRN use of Ativan continued as the benefit was deemed to outweigh the risk. The consultant pharmacist noted that PRN psychotropics require a stop date, and the facility had been advised to implement this. However, the order was not evaluated by the consultant pharmacist until it was eventually discontinued due to non-use. Resident #22, diagnosed with dementia, anxiety, and depression, had a PRN order for Chlordiazepoxide without a stop date. The consultant pharmacist recommended discontinuing the PRN use per guidelines, but the physician extended the use for 90 days, citing that the benefit outweighed the risk. The consultant pharmacist's review failed to identify the continued PRN use without a stop date. The Director of Nursing acknowledged the oversight during an interview, noting that the issue should have been identified during the consultant pharmacist's review.
Failure to Adhere to Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to adhere to the physician's order for fluid restriction for a resident undergoing dialysis. The resident, who was admitted with acute kidney failure and anemia, was on a fluid restriction of 1260 milliliters daily, divided between nursing and dietary allocations. Despite this, observations revealed a full 32-ounce water pitcher in the resident's room, contrary to the physician's order and facility policy, which required the removal of water pitchers for residents on fluid restrictions. Additionally, the breakfast tray provided to the resident contained more fluids than prescribed, with 10 ounces of hot tea instead of the allowed 4 ounces. Interviews with staff indicated a lack of communication and understanding regarding the fluid restriction orders. A Certified Nursing Assistant admitted to providing water pitchers without verifying fluid restrictions, relying on door signs and nurse updates. A Licensed Practical Nurse confirmed the use of door stickers to alert staff about fluid restrictions but was unaware of the specific fluid breakdown for meals, which was the responsibility of the dietary department. This lack of coordination and adherence to the fluid restriction protocol led to the deficiency identified by the surveyors.
Inaccurate Documentation and PICC Line Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a peripherally inserted central catheter (PICC) who was under transmission-based precautions. The resident, who was admitted with diagnoses including acute and subacute infective endocarditis, bacteremia, and sepsis, had specific physician orders for PICC line care. These orders included changing the PICC dressing weekly on Tuesdays and monitoring the IV site every shift. However, the medication administration summary revealed that the dressing was changed daily instead of weekly, and there was no documentation explaining the deviation from the physician's orders. Observations of the resident's PICC dressing on two separate occasions showed that the dressing was clean, dry, and intact but lacked a date, which is a critical component of proper PICC line management. Interviews with the resident, his wife, and a staff LPN confirmed inconsistencies in the dressing change schedule. The resident and his wife reported that the dressing had been changed only once since admission, while the LPN admitted to not checking the date on the dressing and acknowledged that it should have been changed on a specific day, indicating a lapse in following the prescribed schedule.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration for a resident. The facility's policy on standard precautions for infection control, revised in September 2017, requires gloves to be worn whenever exposure to blood, body fluids, or mucous membranes is anticipated. Additionally, the facility's best practice guidelines for medication administration specify that hand hygiene should be performed and gloves worn during procedures such as insulin administration and nasal spray administration. During an observation of medication administration, an LPN did not adhere to these guidelines. The LPN performed hand hygiene before entering the resident's room but did not wear gloves or perform hand hygiene between administering a nasal spray, injecting insulin subcutaneously, and administering oral medications. The LPN justified her actions by stating that gloves were not necessary as there was no blood involved, indicating a misunderstanding of the facility's infection control policies.
Inoperable Emergency Call Systems in Resident Bathrooms
Penalty
Summary
During an inspection of the East Wing on the second floor, it was observed that 6 out of 13 resident room bathrooms had inoperable nurse emergency call systems. The call bells in these bathrooms were wrapped around wall-mounted handrails, rendering them non-functional when pulled. Additionally, the cords were positioned such that they exceeded the minimum requirement of 4 inches from the floor, and bathroom trash containers were obstructing access to the pull cords. This deficiency affected residents requiring varying levels of assistance with toileting, including those needing minimum to maximum assistance and those who were dependent on staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 86 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Naples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Imperial | 1.2 mi | ★★★★★ | 0 | 0 |
| Solaris Senior Living North Naples | 2.9 mi | ★★★★★ | 0 | 0 |
| Renaissance At The Terraces | 3.3 mi | ★★★★★ | 1 | 0 |
| Adviniacare At Naples | 5.1 mi | ★★★★★ | 4 | 0 |
| Premier Place At The Glenview | 6.1 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bentley Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.