Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bennington Glen Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, a history of multiple prior falls, and documented need for substantial assistance and 24-hour supervision with ADLs and toileting was left unattended on the toilet by a CNA who left the room to obtain linens and an adult brief. Despite care plan and fall risk assessments indicating the resident required one to two staff for transfers, ambulation, and toileting, and was unsteady and only able to stabilize with assistance, the CNA exited the bathroom and bedroom. While unsupervised, the resident got off the toilet and was attempting to leave the bathroom when she fell backwards, striking her back and head on the sink. An LPN responding to the incident found the resident on the bathroom floor with a back bruise and a goose egg on her head, and hospital evaluation later confirmed multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, all associated with this fall. Facility documentation and interviews confirmed that the resident was known to frequently get up without assistance and was generally not left alone on the toilet, but on this occasion the established supervision and assistance requirements were not followed, leading to the fall and injuries.
A resident with dementia, severe cognitive impairment, depression, visual and hearing impairments, and other comorbidities had documented preferences on the MDS for reading materials, music, and being around animals, but the activity assessment was completed only with the resident, not family, and concluded the resident could not identify preferred activities. The care plan inconsistently described the resident as sociable with interests in arts and crafts, bingo, and music, yet noted no current activities of interest, and a later activity participation review was left incomplete. Activity records listed daily relaxation and media-based activities and one-on-one reading, but staff later clarified that relaxation meant the resident was simply resting in bed and that recorded one-on-one sessions did not actually occur because the resident was asleep. Surveyors repeatedly observed the resident awake in a dark room with no television, music, reading materials, or other entertainment, and staff were unable to state the resident’s specific activity preferences, demonstrating a failure to adequately assess and implement individualized activity services.
Surveyors found that the facility’s medication error rate exceeded 5% after observing an LPN crush and administer four medications that were listed on the facility’s do-not-crush list. A resident with atrial fibrillation, polyosteoarthritis, and GERD was ordered Metoprolol Succinate ER (two strengths totaling 75 mg daily), Pantoprazole Sodium delayed release, and Tylenol eight hour arthritis pain ER. Despite a standing order that explicitly excluded delayed release/ER and do-not-crush medications from being crushed, the LPN crushed all four of these medications and gave them mixed in pudding, resulting in four medication errors out of 34 opportunities and an 11.76% error rate.
A resident with hypothyroidism had a physician order for daily Synthroid 175 mcg, but the MAR contained no documentation of this medication on multiple specified days, and the medical record lacked any explanation for the missing entries. A regional RN confirmed there was no documentation accounting for the absence of Synthroid documentation, resulting in a cited failure to maintain accurate medical records.
The facility failed to maintain proper infection control when toothbrushes for two residents who required staff assistance with oral hygiene were stored without protective barriers. One resident had neurologic and mobility-related conditions, and another had dementia, chronic respiratory failure, and joint disease, with documentation showing dependence on staff for oral care. During observation of their shared bathroom, a toothbrush was found resting directly on a paper towel dispenser, and multiple toothbrushes were placed on the sink without barriers, stacked on another toothbrush and toothpaste. An LPN acknowledged that the toothbrushes were not stored to prevent potential contamination.
Delayed Accommodation of Wheelchair Needs: A resident with contracture, OA, osteoporosis, and impaired cognition was changed from a donated wheelchair to a different chair with anti-rollbacks after a transfer-related fall. The resident reported the replacement wheelchair was harder to maneuver and pulled to one side, causing her to avoid activities and refuse care, while staff and the DON acknowledged the concern had been known for weeks with mostly verbal communication and little documentation.
Failure to Notify Physician of Significant Weight Gain: The facility did not timely notify the physician of significant weight changes for two residents with CHF who were on scheduled weight monitoring. One resident exceeded an ordered weight threshold on two weights without documented physician notification, and another resident had a 16.4% weight gain with no documentation of nursing or dietary follow-up, physician or RD notification, or a re-weigh before the next scheduled weight.
Antibiotic stewardship was not followed for a resident with CKD who reported dysuria and had a urine culture showing mixed growth and probable contamination. Despite no documented C&S sensitivity results or organism susceptibility profile to guide therapy, the physician ordered Cephalexin for presumed UTI, and the antibiotic was administered as ordered.
The facility failed to complete timely quarterly MDS 3.0 assessments for nine residents, affecting those with conditions like dementia and Alzheimer's. Assessments were either incomplete or overdue, as confirmed by the MDS Coordinator. The RAI Manual mandates quarterly assessments every 92 days, which the facility did not meet, leading to the deficiency.
The facility failed to ensure pureed food was prepared to a smooth texture before serving it to residents on a pureed diet. Observations and staff interviews revealed that the pureed chicken enchilada was chunky and required chewing, contrary to the expected smooth consistency. Despite this, it was deemed acceptable to serve. This issue had the potential to affect several residents on a prescribed pureed diet.
The facility failed to conduct proper contact tracing and implement timely outbreak procedures when staff and residents tested positive for COVID-19. A resident with symptoms was not tested promptly and continued to share a room with a negative roommate. The facility delayed outbreak response despite multiple positive cases, affecting 14 residents.
The facility failed to implement its antibiotic stewardship program, affecting 13 residents who were prescribed antibiotics without meeting necessary criteria. Infection control logs were incomplete, and there was no documentation of communication with prescribing physicians. The facility's policies on infection control and antibiotic stewardship were not followed, with no evidence of staff training or feedback reports.
The facility failed to prevent the loss of clothing for a resident and maintain a clean environment for another. A resident reported missing clothing, which was a recurring issue in council meetings, while another resident experienced a persistently sticky floor despite daily cleaning protocols. These deficiencies highlight lapses in the facility's laundry and housekeeping practices.
The facility failed to complete timely MDS 3.0 assessments for three residents, as required by OBRA 1987. A resident with dementia, depression, and Parkinson's Disease had an incomplete annual assessment, while another with dementia, anxiety, and depression also had an incomplete assessment. Additionally, a resident with respiratory failure and congestive heart failure had an incomplete admission assessment. These deficiencies were confirmed by the MDS Coordinator.
The facility failed to maintain a pest-free environment in the food preparation and service areas, affecting all 74 residents. Observations revealed flies in the kitchen, and despite regular pest control visits, the issue persisted. The facility's policy emphasizes maintaining a clean environment, but ongoing fly activity was noted.
A resident with Alzheimer's, hyperlipidemia, and hypertension experienced a medication order transcription error upon admission. The facility failed to accurately transcribe physician's orders for Losartan, initially omitting parameters for its administration, and included an unauthorized order for Atorvastatin. The resident's family and the DON confirmed discrepancies, highlighting a failure to adhere to medication administration policies.
A resident with Alzheimer's, hyperlipidemia, and hypertension was administered Losartan outside of physician-ordered parameters, despite instructions to hold the medication if blood pressure was below 130/80 mmHg. The resident received the medication on six occasions with blood pressure readings below the threshold, indicating a significant medication error.
A facility failed to properly label and store medications, affecting a resident and potentially impacting others. A resident was found with nasal sprays at his bedside without an order for self-administration, and an LPN discovered improperly labeled medications in a cart. The DON confirmed that medications should not be pre-poured and must be stored securely.
Unsupervised Toileting of High-Risk Resident Resulting in Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with toileting for a resident with a known high risk of falls, resulting in a serious fall and injuries. The resident had dementia, a history of falls, periprosthetic fracture around an internal prosthetic of the left hip joint, a fracture of the neck of the left femur, age-related macular degeneration, and osteoarthritis. Her care plan, initiated and revised prior to the incident, identified her as at risk for falls due to dementia, decreased mobility, increased weakness, unsteady gait, and a history of multiple prior falls when attempting to stand, transfer, or ambulate without assistance. The care plan and fall risk evaluation documented that she required assistance from one to two staff for all transfers, ambulation, and toileting, had severely impaired cognition, and needed substantial or maximal assistance with toileting hygiene and transfers, as well as 24-hour supervision and assistance during ADLs and transfers. In the months preceding the incident, the resident experienced multiple falls, including events on 10/12/25, 10/29/25, 11/07/25, 12/02/25, and 12/25/25, each occurring when she attempted to stand, transfer, or ambulate without assistance. A fall risk evaluation dated 12/25/25 further documented that she was cognitively impaired, unable or unwilling to follow directions, and displayed behaviors such as restlessness, wandering, resisting care, and altered safety awareness. She was unsteady and only able to stabilize with assistance when moving from seated to standing, walking, moving on and off the toilet, and transferring between surfaces. Occupational therapy records indicated she required maximum assistance of one staff member for transfers from various surfaces and multimodal cues to increase ADL performance, reinforcing that she required continuous supervision and assistance during ADLs and transfers. On 03/21/26, despite these documented risks and needs, the resident was left unattended on the toilet by a CNA who was unfamiliar with her and her fall risks. According to the progress note and fall investigation, the CNA placed the resident on the toilet and then left the bathroom and bedroom to obtain new bedding and an adult brief from the hallway linen closet. While the CNA was away, the resident got herself off the toilet. When the CNA returned, she observed the resident coming out of the bathroom door and saw her fall backwards, striking her back and head on the sink. Initial documentation and the fall questionnaire indicated the CNA found the resident standing and that the resident became startled and fell back, with no mention that the CNA assisted her to the floor. The LPN who responded to the incident found the resident on the bathroom floor with a bruise on her back and a goose egg on the back of her head and documented that the CNA reported seeing the resident fall and being unable to reach her in time to assist. Subsequent hospital evaluation documented multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, which were associated with this fall. The facility’s own investigation noted that the resident had been left alone in the bathroom and added an intervention for staff to remain in the bathroom until the resident finished toileting, underscoring that the lack of supervision during toileting led to the fall and resulting injuries. Additional interviews supported that residents with similar cognitive impairment and toileting needs were generally not left alone on the toilet and required frequent checks, with staff often remaining in or just outside the bathroom to monitor them. The LPN confirmed that this resident was known to frequently get up without assistance and, for that reason, was not typically left alone on the toilet. The administrator acknowledged that staff from other buildings, who were unfamiliar with residents and their risks and were unlikely to review care plans, were being used at the time of the incident. The facility’s fall management policy required ongoing review of care plans and use of fall risk evaluations to identify individualized fall risk factors, but in this case, the CNA did not follow the resident’s established need for continuous supervision and assistance during toileting, directly leading to the unsupervised toileting event and subsequent fall. The hospital records following the incident documented that the resident presented after a mechanical fall with chest wall pain and visible bruising to the left side. Imaging and physician notes identified left-sided rib fractures (seventh through eleventh ribs), a small left hemopneumothorax, an acute left T9 transverse process fracture, and hematomas of the left chest wall, retroperitoneum, and right iliacus muscle. The records stated it was unknown whether osteopenia or osteoporosis contributed to the fractures and did not characterize the fractures as pathological. The physician noted that the resident was at high risk of falls and had been sent to the emergency room after this fall, confirming that the injuries were associated with the incident in which she was left unattended while toileting. The facility’s documentation of the event, including the fall investigation and questionnaires, consistently indicated that the resident was left alone in the bathroom despite her documented need for assistance and supervision with toileting and transfers. The lack of a contemporaneous witness statement from the CNA and the later, typed statement created over a month after the fall introduced discrepancies about whether the CNA partially assisted the resident to the floor. However, the LPN’s account and initial documentation emphasized that the CNA reported seeing the resident fall and being unable to reach her in time, and that the resident struck her head and back on the sink. These facts, combined with the resident’s known fall risk profile and care plan requirements, form the basis of the deficiency for failing to ensure adequate supervision and assistance to prevent accidents during toileting. The facility’s fall management policy, revised 10/24/25, required that care plans be reviewed throughout treatment to ensure resident-specific fall reduction interventions were incorporated and that fall risk evaluations be completed on admission, after significant changes, quarterly, and as necessary. The resident’s care plan and evaluations had already identified her need for assistance and supervision with toileting and transfers, yet on the day of the incident, these interventions were not followed when the CNA left her unattended on the toilet. This failure to adhere to the resident’s individualized fall prevention measures and to provide adequate supervision in the bathroom directly preceded the resident’s unsupervised attempt to ambulate, her fall, and the serious injuries documented in the hospital records.
Failure to Adequately Assess and Implement a Resident’s Activity Preferences
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and honor a resident’s activity preferences and to meet the resident’s identified needs for meaningful activities. The resident had dementia, severe cognitive impairment with a BIMS score of six, depression, age-related macular degeneration, osteoarthritis, and sensorineural hearing loss. The comprehensive MDS assessment documented that it was somewhat important to the resident to have books, newspapers, and magazines to read, to listen to music, and to be around animals such as pets. Despite this, the activity participation assessment dated 10/06/25 noted the resident was hard of hearing and hard to communicate with, was completed only with the resident and not the family, and concluded the resident was unable to identify preferred activities. The plan of care dated 11/06/25 described the resident as sociable, liking to participate in various activities, and willing to interact with others and participate in activities related to their interests as their condition allowed. It also stated the resident had no current activities of interest and was unable to pursue interests due to physical and/or cognitive condition, while listing arts and crafts, bingo, and music as important activities. Interventions included discussing the activity calendar, encouraging rest so the resident could attend preferred activities, and inviting the resident to music-related and scheduled activities. However, the subsequent activity participation review dated 12/15/25 was not completed, and the Activities Director reported trying to identify the resident’s preferred activities but could not refer to any documentation of this, and thought she had spoken to the family but acknowledged it might not be documented. Activity participation records from 04/01/26 to 04/19/26 showed daily participation in relaxation, television/radio/movies, and news events, and documented one-on-one and reading activities on two dates, although the Activities Assistant later stated the resident had been asleep during those one-on-one sessions and that relaxation meant the resident was simply resting in bed. Multiple observations on 04/20/26 and 04/21/26 found the resident awake in a dark room with no television, music, reading materials, or other entertainment, and an empty bedside table. A CNA confirmed the resident was sitting in the dark without any form of entertainment and was unsure of the resident’s music or television preferences. The RAI User’s Manual guidance cited in the report states that activity preference information should be obtained from the resident or, if not possible, from family or others, and used to create an individualized plan based on the resident’s preferences, underscoring that the facility did not adequately assess and implement the resident’s activity preferences as required.
Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 34 opportunities, resulting in an 11.76% error rate. The affected resident had an admission date of 09/25/18 and diagnoses including paroxysmal atrial fibrillation, polyosteoarthritis, and gastro-esophageal reflux disease (GERD) without esophagitis. Physician orders for this resident included Metoprolol Succinate ER 25 mg once daily and Metoprolol Succinate ER 50 mg once daily (for a total of 75 mg daily), Pantoprazole Sodium delayed release 20 mg once daily, and Tylenol eight hour arthritis pain ER 650 mg twice daily. There was also a standing order allowing nursing to crush medications or open capsules and mix them in food or drink unless the medications were delayed release/ER, enteric coated, or listed on the facility’s do not crush list. During observation and interview on 04/22/26 at 8:00 A.M., an LPN crushed the resident’s Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg, Metoprolol Succinate ER 50 mg, and Pantoprazole Sodium delayed release 20 mg and administered all four crushed medications in pudding. The LPN confirmed that she had crushed and administered these four medications in this manner. Review of the facility’s do not crush list showed that all four of these medications—Tylenol eight hour arthritis pain ER 650 mg, Metoprolol Succinate ER 25 mg and 50 mg tablets, and Pantoprazole Sodium delayed release 20 mg—were specifically listed as medications that were not to be crushed, directly leading to the identified medication errors and the elevated medication error rate.
Failure to Maintain Accurate MAR Documentation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation for one resident. The resident was admitted on 10/15/21 with diagnoses that included hypothyroidism and had a physician’s order for Synthroid 175 mcg orally once daily for this condition. Review of the resident’s Medication Administration Record (MAR) showed that there was no documentation of Synthroid administration on 04/10/26, 04/11/26, 04/14/26, 04/15/26, and 04/16/26. The medical record contained no explanation or documentation indicating why the Synthroid was not documented on those dates. In an interview on 04/22/26 at 8:25 A.M., the Regional Registered Nurse confirmed that there was no documentation in the medical record regarding the missing Synthroid entries on the MAR. This deficiency was identified during an investigation under Complaint Number 2603937 and reflects non-compliance with requirements to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Improper Toothbrush Storage Compromises Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to ensure toothbrushes were stored in a manner that maintained infection control for two residents who required assistance with oral hygiene. One resident, admitted with diagnoses including dysarthria and anarthria, demyelinating disease of the central nervous system, and muscle weakness, had an ADL care plan indicating a need for assistance with oral hygiene. Another resident, admitted with diagnoses including dementia, chronic respiratory failure, and unilateral post-traumatic osteoarthritis of the left hand, also had an ADL care plan indicating a need for assistance with oral hygiene, and an MDS assessment documenting dependence on staff for oral hygiene. During observation of their shared bathroom, surveyors found a toothbrush resting directly on the bottom of a paper towel dispenser without a barrier, and two identical toothbrushes resting on the sink between the faucet and wall with no barrier, placed atop another different type of toothbrush and a bottle of toothpaste. In an interview, an LPN confirmed that the toothbrushes were not stored in a way that would prevent potential contamination. This deficiency represents non-compliance with infection prevention and control requirements as investigated under Complaint Number 2974213.
Delayed Accommodation of Wheelchair Needs
Penalty
Summary
The facility failed to timely address a resident’s request for accommodation of mobility needs. Resident #7 was admitted with contracture, bilateral primary osteoarthritis of the knee, and age-related osteoporosis without current pathological fracture, and the significant change MDS indicated impaired cognition. The resident required setup assistance for wheelchair mobility and supervision for walking. After a staff transfer incident in which the resident was lowered to the floor when the wheelchair rolled backward during transfer, the resident later reported that staff had switched out her wheelchair and that the replacement chair was much harder to maneuver and pulled to the right. The resident stated she did not know why her old wheelchair had been removed and reported that she was running into walls and people with the new chair. She also refused a shower after multiple attempts and voiced dissatisfaction with the replacement wheelchair, remaining in a recliner by choice. Staff confirmed the resident had previously used a donated wheelchair that did not have anti-rollbacks, and the facility changed her to a different wheelchair that matched the care plan and included anti-rollbacks after the fall. Staff and the Administrator acknowledged the resident had been concerned about the wheelchair for at least a month, that management had been informed, and that communication about the concern was mostly verbal with only one text message located.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to ensure the physician was timely notified of significant weight changes for two residents with congestive heart failure who were being weighed on a scheduled basis. Resident #19 had diagnoses including chronic heart failure and an order to weigh before breakfast on Monday, Wednesday, and Friday, with the physician to be notified if the weight was over 180 pounds. The resident weighed 186.2 pounds and then 188.4 pounds, but the medical record contained no evidence that the physician was notified of either weight exceeding the ordered threshold. Regional Nurse #450 verified there was no evidence of physician notification for those weights. Resident #45 had chronic diastolic congestive heart failure and an active order for weights every three days related to CHF. The resident weighed 114.6 pounds and then 133.4 pounds, a 16.4 percent weight gain, but there was no documentation that nursing staff or dietary staff addressed the change. There was also no documentation of physician notification, dietitian notification, or a re-weigh before the next scheduled weight. An LPN stated a 16 percent weight gain would require a re-weigh and that the recent weight should have been re-weighed because it was most likely an error. The MD could not specifically confirm notification, and the RD confirmed she was not notified of the weight gain.
Antibiotic Stewardship Not Followed for UTI Treatment
Penalty
Summary
The facility failed to ensure antibiotic stewardship was followed for a resident admitted with chronic kidney disease. The resident reported burning with urination, and a urine culture and sensitivity was ordered. The urine specimen was collected the next morning, and the culture later showed greater than 100,000 colonies per milliliter of gram-negative bacilli, 10,000 to 50,000 colonies per milliliter of Proteus species, and additional flora indicative of probable vaginal or urethral contamination. The report also stated that three or more organisms were present, suggesting contamination, and that susceptibility testing was not recommended for contaminated urine specimens. Despite the contaminated culture result and the absence of documented sensitivity testing to guide organism-specific therapy, the physician was notified and Cephalexin 500 mg by mouth every 12 hours for five days was ordered for treatment of UTI. The medication was administered as ordered and completed. Review of the medical record showed no documented urine culture sensitivity results available before Cephalexin was started, and there was no evidence that an organism susceptibility profile was obtained or used to determine whether the antibiotic was appropriate for the identified organisms. A regional nurse confirmed that no sensitivity testing was available to determine whether Cephalexin was an appropriate antibiotic choice.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) 3.0 assessments were completed in a timely manner for nine residents out of 36 reviewed. These residents included individuals with diagnoses such as dementia, Alzheimer's disease, chronic respiratory failure, Parkinson's disease, cerebral infarction due to embolism, and acquired absence of a limb. The assessments were either incomplete or overdue, as confirmed by the MDS Coordinator during interviews. For Resident #14, the quarterly assessment was in progress but overdue, with the last assessment completed on 06/01/24. Similarly, Resident #15's quarterly assessment was also in progress and overdue, with the last annual assessment dated 05/30/24. Resident #23's quarterly assessment was overdue, with the last admission assessment completed on 05/20/24. Resident #27 had two quarterly assessments listed as in progress, with the last completed assessment being a significant change in status assessment dated 04/03/24. Other residents, such as Resident #30, #47, #52, #56, and #60, also had overdue quarterly assessments, with their last assessments completed several months prior. The RAI Manual requires that quarterly assessments be completed at least every 92 days following the prior OBRA assessment, and the facility's failure to adhere to this requirement resulted in the deficiency noted in the report.
Inappropriate Texture of Pureed Food Served to Residents
Penalty
Summary
The facility failed to ensure that pureed food was prepared to an appropriate smooth texture before serving it to residents on a pureed diet. This deficiency was identified through observations and staff interviews, which revealed that the pureed chicken enchilada prepared by Dietary [NAME] (DC) #344 was chunky and required chewing, contrary to the expected smooth, mashed potato-like consistency. Despite tasting the puree and acknowledging its chunkiness, DC #344 deemed it acceptable to serve. The Dietary Supervisor also confirmed the puree's chunky texture. The facility's undated Pureed Food policy mandates that food be provided in a form designed to meet individual needs, and pureed diets should be served as ordered by the physician. This issue had the potential to affect five residents on a prescribed pureed diet, with a facility census of 74.
Inadequate COVID-19 Response and Delayed Outbreak Procedures
Penalty
Summary
The facility failed to properly conduct contact tracing and implement broad-based testing when staff and residents tested positive for COVID-19. This deficiency affected 14 residents and was identified through observations, policy reviews, and interviews with residents and staff. The facility did not offer an alternative room to a resident whose roommate tested positive for COVID-19, and the resident was not tested in a timely manner despite exhibiting symptoms. Additionally, there was a lack of tracking information for several staff members and residents who tested positive, and the facility delayed implementing outbreak procedures. The facility's COVID-19 tracking information revealed multiple positive cases over a 27-day period, with inadequate tracking and contact tracing for several individuals. For instance, a Certified Nursing Assistant and a housekeeper tested positive, but no tracking was provided for their contacts. Similarly, several residents tested positive without proper tracking of their close contacts, and there was a delay in identifying an outbreak despite multiple positive cases. The Infection Preventionist (IP) acknowledged the delay in implementing outbreak procedures and the lack of comprehensive tracking for all positive cases. Resident #3, who had a history of type II diabetes, chronic kidney disease, obesity, and obstructive sleep apnea, exhibited symptoms of COVID-19 but was not tested promptly. Despite complaints of head congestion, cough, and nasal congestion, the resident was not isolated and continued to share a room with a roommate who tested negative. The facility's policies required contact tracing and testing upon identification of a positive case, but these procedures were not followed effectively, leading to a delay in outbreak response and inadequate isolation measures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy effectively, impacting 13 out of 17 residents who were prescribed antibiotics during September and October 2024. The infection control logs for September 2024 revealed that eight residents did not meet the criteria for appropriate antibiotic use. For instance, Resident #177 was prescribed Amoxicillin for pneumonia without any recorded respiratory symptoms or an x-ray, and Resident #54 was given Ciprofloxacin for a UTI without a culture or urinary symptoms. These instances indicate a lack of adherence to the facility's policy requiring specific criteria to be met before administering antibiotics. The infection control log for October 2024 was incomplete, listing only six residents with minimal information such as onset dates, antibiotic names, and resolved dates, some of which were inaccurately recorded as future dates. There were no details on the site of infection, infection-related diagnosis, or any performed cultures or x-rays. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that multiple residents did not meet the criteria for antibiotic use, and there was no documentation of communication with the prescribing physician regarding these discrepancies. The facility's policies on infection control and antibiotic stewardship were not followed, as evidenced by the lack of documentation, incomplete logs, and absence of staff or provider training on antibiotic stewardship. The DON acknowledged that the primary physician was reasonable and should have been informed about residents not meeting infection criteria. However, there was no evidence of feedback reports or educational efforts related to antibiotic use, indicating a systemic failure in maintaining the facility's antibiotic stewardship program.
Deficiencies in Laundry and Housekeeping Practices
Penalty
Summary
The facility failed to prevent the loss of a resident's clothing and maintain a clean environment, affecting two residents. Resident #48, who is cognitively intact, reported missing a shirt and shorts, which were not found despite being discussed in resident council meetings and with the Head of Housekeeping/Laundry. The issue of missing clothing was a recurring topic in resident council meetings, indicating a persistent problem with the facility's laundry process. Resident #224, who has a history of spinal fractures and is at risk for falls, experienced a consistently sticky floor in his room over several days. Despite daily cleaning protocols, the floor remained sticky, as confirmed by multiple staff members and the resident himself. The facility's policies require daily cleaning to maintain a sanitary environment, yet the sticky floor persisted, suggesting a failure in housekeeping practices.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete timely and required comprehensive Minimum Data Set (MDS) 3.0 assessments for three residents, as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987. Resident #35, diagnosed with dementia, depression, and Parkinson's Disease, had an incomplete annual MDS assessment dated 08/27/24, which was not submitted as required, with the previous assessment dated 08/30/23. Similarly, Resident #39, with diagnoses of dementia, anxiety, and depression, had an annual MDS assessment in progress dated 08/20/24, following a prior assessment on 08/21/23. Both cases were confirmed by MDS Coordinator #393 during an interview. Additionally, Resident #171, who suffers from acute and chronic respiratory failure with hypoxia and congestive heart failure, had an incomplete admission MDS assessment dated 09/26/24, with no prior comprehensive assessments recorded. The RAI Manual specifies that comprehensive assessments, including the MDS and Care Area Assessment (CAA) process, must be completed upon admission, annually, and when significant changes occur. The facility's failure to adhere to these requirements for the specified residents was confirmed through staff interviews and record reviews.
Pest Control Deficiency in Food Service Areas
Penalty
Summary
The facility failed to maintain a pest-free environment in the food preparation and service areas, which had the potential to affect all 74 residents. Observations and interviews conducted on multiple occasions revealed the presence of flies in the kitchen, including on the ceiling, beverage line, food preparation station, and near the food steam table. The Dietary Supervisor acknowledged the fly issue and confirmed that an exterminator had visited the facility, but the problem persisted. The facility's pest control invoices indicated an increase in fly activity starting from September, with ongoing issues noted in subsequent visits. Despite utilizing a pest control specialist every two weeks, the facility continued to experience fly activity in the kitchen area. The facility's Insect/Rodent Control policy, dated January 2016, emphasizes the responsibility to ensure a safe, clean, and homelike environment, which includes minimizing the presence of pests.
Medication Order Transcription Error
Penalty
Summary
The facility failed to accurately transcribe physician's orders for medications upon the admission of a resident, identified as Resident #90, affecting the quality of care provided. Resident #90, who had medical diagnoses including Alzheimer's disease, hyperlipidemia, and hypertension, was admitted for a planned respite stay. Upon review, it was found that the physician's orders for Losartan, a medication for hypertension, were not correctly transcribed. The original order specified to hold Losartan until the resident's blood pressure was over 130/80 mmHg and to reduce the dose to 50 mg when restarting. However, the facility's records showed an order for Losartan 100 mg daily without these parameters until it was modified three days later. Additionally, there was an unauthorized order for Atorvastatin, a cholesterol-lowering medication, which was not included in the written physician's orders provided upon admission. The resident's Medication Administration Record (MAR) indicated that Atorvastatin was administered on three occasions, despite the medication not being available on other days. There was no documentation or communication with a medical provider to verify the source of the Atorvastatin order, leading to concerns about the accuracy of medication administration. Interviews with the resident's family and the Director of Nursing (DON) confirmed discrepancies in the medication orders. The family member expressed concern about the resident receiving incorrect medications, and the DON acknowledged the lack of documentation questioning the Losartan order and the absence of a source for the Atorvastatin order. The facility's policy on medication administration emphasized the importance of administering medications according to prescriber's orders, which was not adhered to in this case.
Failure to Adhere to Medication Parameters for Blood Pressure Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Losartan, a medication used to lower blood pressure. The resident, who had a history of Alzheimer's disease, hyperlipidemia, and hypertension, was admitted for a planned respite stay. The resident's medical records indicated that Losartan should only be administered if the blood pressure reading was over 130/80 mmHg, with a reduced dosage of 50 mg upon restarting the medication. However, the facility's electronic health record contained an order for Losartan 100 mg once daily, with parameters to hold the medication if the blood pressure was below 130/80 mmHg. Despite these parameters, the resident's Medication Administration Record (MAR) showed that the resident received Losartan on multiple occasions when their blood pressure was below the specified threshold. Specifically, the medication was administered on six different dates when the resident's blood pressure readings were below 130/80 mmHg, with the lowest recorded at 96/62 mmHg. The Director of Nursing confirmed that the medication was administered outside of the physician-ordered parameters and acknowledged that the nurses involved required re-education. The facility's policy on medication administration emphasized adherence to prescriber orders, which was not followed in this case.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to label and store medications in a safe and secure manner, affecting one resident directly and potentially impacting 18 others. Resident #55, who had intact cognition, was found to have nasal sprays at his bedside without an order for self-administration. The resident admitted to frequently administering his own nasal sprays, which were sometimes left at his bedside by nursing staff. The LPN confirmed that there was no order for the resident to self-administer medications or to keep them at his bedside, and subsequently removed the nasal sprays. Additionally, an observation revealed three plastic pill cups in the top drawer of Cart A, containing medications that were not properly labeled. One cup was marked with a resident's first name, another with "Fe" for iron supplements, and the third was unlabeled. The LPN was unable to verify the strength of the iron supplements and did not know who the unlabeled pills were for. The medications were disposed of after the LPN confirmed they should not have been stored in this manner. The Director of Nursing confirmed that medications should not be pre-poured and must be stored in appropriate packages with labels.
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 508 citations issued within 25 miles in the last 12 months — including the 2 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 Marengo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Centerburg Respiratory & Specialty Rehab Ctr | 8.5 mi | — | 0 | 0 |
| Centerburg Pointe | 8.9 mi | ★★★★★ | 6 | 0 |
| Morrow Manor Nursing Center | 10.1 mi | ★★★★★ | 16 | 0 |
| Country View Of Sunbury | 10.7 mi | ★★★★★ | 0 | 0 |
| Woodside Village Care Center | 11.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bennington Glen Nursing & Rehabilitation 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 July 2026) and official state health department websites.