Bedford Care Center Of Mendenhall

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

39.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 60 beds and averages 55.9 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.56 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.75 hrs/resident/day on weekends vs 4.26 on weekdays — 12% thinner on weekends. RN hours go from 0.67 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 16 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-08-05 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions to prevent burns and for the use of tobacco for one (1) of seven (7) sampled residents. (Resident #1) The facility's failure to develop comprehensive care plan interventions resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia - left side, Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and the IJ removed on 8/3/24. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-08-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision to prevent a burn from hot coffee for one (1) of seven (7) sampled residents, with the potential to affect all residents who drink coffee in the Dining Room. Resident #1 The facility's failure to ensure adequate supervision resulted in Resident #1, who had diagnoses including Diabetes Mellitus (DM, Hemiplegia (left side), Vascular Dementia, and moderately impaired cognition sustaining a third-degree burn to his left thigh and placed other residents who drink hot coffee at risk for sustaining serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 4/11/24 when Resident #1 sustained a third-degree burn to his left thigh. The facility Administrator was notified of the IJ on 8/2/24 at 11:15 AM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 8/2/243, in which they alleged all corrective actions to remove the IJ were completed on 8/2/24, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-12-17 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors by failing to accurately reconcile hospital discharge medications and ensure timely and accurate medication administration, which resulted in missed doses of prescribed antibiotic therapy and subsequent rehospitalization for wound infection and dehiscence (surgical incision that opens or pulls apart) for Resident #1 and duplicate administration of antihypertensive medications for Resident #2, affecting two (2) of four (4) sampled residents.Findings Include:Review of the facility's policy, Administering Medications revised 8/02/22, revealed, .Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.3. Medications must be administered in accordance with the orders, including any required time frame.17. The individual administering the medication must initial the resident's EMAR (Electronic Medication Administration Record) on the appropriate line after giving each medication…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-05 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, and record review, the facility failed to ensure a resident's right for self-determination as evidenced by facility staff taking a resident's chewing tobacco without notice, which he was previously granted permission to have, and resulted in the resident crying and begging in distress and continued fear of staff taking away his tobacco for one (1) of three (3) residents sampled for tobacco usage. (Resident #1) Findings include: A record review of the facility's policy Smoking/Tobacco -Free Policy-Residents dated 2019 revealed .All residents, employees, and visitors are prohibited from using any type of tobacco, snuff, e-cigarettes, and similar products, in company buildings, parking areas, on company property, or in any company owned or leased vehicle. No resident who uses any of these products will be admitted unless the Resident and Resident Representative agree for the Resident to accept and continue a smoking cessation program or cessation patch . A record review of the facility's policy Resident Rights with revision date of 06/01/23 revealed .…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-13 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY CI MS #23522 Based on staff interviews, record reviews, and facility policy and procedure reviews, the facility failed to implement the care plan for a two (2) person transfer using a full body lift, resulting in an injury to Resident #1 for one (1) of three (3) care plans reviewed for transfers. Based on implementation of the facility's corrective actions initiated on 11/09/23-11/12/23, this was determined to be Past Non-Compliance (PNC). Findings Include: The facility policy and procedure titled Using the Care Plan dated revised 8/2/22 revealed: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident The facility policy and procedure titled Comprehensive Care Plans dated revised 8/24/22 revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a resident's medical, nursing needs. Policy…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2023-12-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY CI MS 23522 Based on record reviews, interviews, and facility policy and procedure review the facility failed to ensure a resident was free of accidents and/or hazards during transfer when staff physically lifted and transferred Resident #1 from her bed to her wheelchair without using the required full body lift with two (2) person (s) to assist, resulting in a fracture of the left tibia and fibula and a left non-displaced intertrochanteric femur fracture for one (1) of three (3) residents reviewed for accident/hazards. Resident #1. Based on implementation of the facility's corrective actions on 11/09/23 through 11/12/23, this was determined to be Past Non-Compliance. Findings include: Record review of the facility policy and procedure titled Resident Lift/Transfer Policy and Procedure Acknowledgement for Nurses and Certified Nursing Assistants dated 01/01/2019 revealed It is the Policy of (Proper Name of Facility)this facility) to provide a safe environment for .Residents by providing mechanical lift equipment…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-06-25 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and facility policy review the facility failed to implement comprehensive care plans for two (2) of (15) sampled Residents. Residents #14 and Resident #42.Findings include: A record review of the facility policy Comprehensive Care Plan, revised 8/24/22, revealed, Policy: It is the facility's policy to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs identified through the comprehensive assessment . A record review of the facility policy titled Safe Transfer and Lifting of Residents, revised 8/2/22, revealed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents.V. c. Identifies resident/ensures proper transfer is followed per care plan. Resident #14 Record review of the Incident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Dcited before2026-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure residents were transferred using the care planned mechanical lift, resulting in Resident #14 being transferred with an inappropriate sit to stand lift rather than the required total lift for one (1) of three (3) residents who required a lift for transfers.Findings include:A record review of the facility policy titled Safe Transfer and Lifting of Residents, revised 8/2/22, revealed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents.V. c. Identifies resident/ensures proper transfer is followed per care plan.Record review of the Incident Investigation Summary dated 4/20/26 revealed, .The investigation identified that the CNA did not follow the resident care plan and facility policy related to transfer technique during the shifts on 4/15/26.On 6/23/26 at 2:02 PM, during a phone interview,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2025-02-06 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and facility policy review, the facility failed to follow infection prevention guidelines by improperly implementing enhanced barrier precautions, failing to adhere to handwashing/hand hygiene practices during care and failed to ensure clean and soiled items were not stored together in a biohazard room for two (2) of four (4) days of survey that affected Resident #13 and Resident #31. Findings Include: A record review of the facility's Enhanced Barrier Precautions policy dated 3/7/24 revealed .Policy Explanation and Compliance Guidelines .2. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), even if the resident is not known to be infected or colonized with a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-06 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews and facility policy review the facility failed to ensure resident rights were honored as evidenced by Resident #44 was not allowed to get out of bed as requested and residents not receiving preferred snacks at bedtime for five (5) of 31 sampled residents reviewed for choices. Resident #26, Resident #33, Resident #40, and Resident #41 and Resident #44 Findings Include: Resident #44 A record review of the facility's Resident Rights with a revision date of 6/1/23 revealed .4. Respect and dignity .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . On 02/03/25 at 11:37 AM, in an interview and observation Resident #44 in bed. She stated she wants to get up, but they (facility staff) won't get me up. Resident #44 stated she wants to go activities, but they won't get her up out of bed. She stated she is in bed all the time. On 02/03/25 at 02:25 PM, during an observation and interview revealed Resident #44 was in bed watching TV. She stated the facility staff does not…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, facility policy review, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for two (2) of five (5) residents observed for care (Resident #13 and Resident #31). Findings include: Resident #13 Record review of the facility policy Comprehensive Care Plans, revised on 08/24/22, revealed It is the policy of this facility to develop a comprehensive, person-centered care plan for each resident Record review of the facility policy Gastrostomy/Jejunostomy Site Care, revised 08/02/22, revealed .Preparation . 2. Review the resident's care plan and provide for any special needs of the resident . Record review of the Order Summary Report with active orders as of 2/5/2025 revealed an order dated 4/12/24 for Enhanced Barrier Precautions related to presence of PEG tube, use of gloves and gown as appropriate when providing care. A record review of Resident #13's care plan revealed Enhanced Barrier Precautions (EBP) related to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-06 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure residents who use enabling devices have physician orders as part of the professional standard of practice for one (1) of (19) residents who use enabling devices in the facility. Resident #52. Findings include: A review of the facility policy, Provision of Quality of Care, revised on September 20, 2022, revealed: . Policy Explanation and Compliance Guidelines .4. Qualified persons will provide the care and treatment in accordance with professional standards of practice On 2/4/25 at 10:38 AM, Licensed Practical Nurse (LPN) #1, stated in an interview that there is no documentation regarding the monitoring of the resident while using the seatbelt. She mentioned that they usually check on her every 15 minutes, but this is not documented. During an interview and record review with the Director of Nursing (DON) on 2/4/25 at 10:49 AM, revealed Resident #52 had been using the seatbelt since December 2024. However, there was not a physician's order for the seatbelt. The DON explained…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-09-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interviews, record review and facility policy review, the facility failed to keep the call light within the resident's reach for two (2) of three (3) observations. Resident #8. Findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, with revised date of 08/02/22, revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . On 09/05/23 at 01:43 PM, an observation of Resident #8 revealed the resident was lying in bed with the head of the bed elevated. The resident's call light was lying on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-09-07 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review the facility failed to ensure a dignified living environment for a resident who had signs regarding her care posted in view of visitors and other residents for one (1) of 15 sampled residents. Resident #23 Findings Include: Review of the facility's Resident Rights, revised 6/1/23, revealed .7. Privacy and confidentiality. The resident has a right to .confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care . On 09/05/23 at 2:49 PM, during an observation of Resident #23, there was a handwritten sign located on her personal refrigerator, within view of other residents and visitors, which indicated Thickened Liquids. On 09/06/23 at 9:30 AM, during an observation of Resident #23, the sign indicating thickened liquids was observed on the resident's personal refrigerator in her room. On 9/7/23 at 10:00 AM, Resident #23 was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-09-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that tube placement was checked prior to flushing the enteral feeding tube with water for one (1) of (1) observations of enteral feedings. Resident #9 Findings include: Review of the policy, Administering Medications through an Enteral Tube, with a revision date of 8/2/22, revealed, .19. For nasogastric (NG) and gastrostomy (G) tubes, check placement: .a. Observer for a change in the external tube length. b. Observe for signs of respiratory distress. C. Auscultate the abdomen, but do not rely on this as the singular method to differentiate between respiratory, gastric, esophageal and bowel placement: (1) Attach 60 mL (milliliter) syringe containing approximately 10 cc (cubic centimeter) air. (2) Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing. (3) Listen for whooshing sounds to check placement of the tube in the stomach . On 09/06/23 at 2:35 PM, observed Licensed Practical Nurse (LPN) #2 flushing the peg…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-09-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #8 Findings Include: Review of the facility's policy, Oxygen Administration, with revised date of 08/02/22, revealed, Purpose .The purpose of this procedure is to provide guidelines for safe oxygen use . Equipment and Supplies .The following equipment .will be necessary when performing this procedure .4. No Smoking/Oxygen in Use signs . Steps in the Procedure . 2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door . On 09/05/23 at 11:21 AM, an initial observation of Resident # 8, revealed the resident was receiving oxygen by way of nasal cannula using an oxygen concentrator. There was no cautionary signage on the door of the room, indicating that oxygen was being administered. Observation on 09/05/23 at 01:43 PM, revealed Resident #8, was lying in bed with the head of bed elevated and receiving oxygen by way of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$79,758 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $40,404 — penalty dated 2025-12-17
• $30,602 — penalty dated 2024-08-05
• $4,376 — penalty dated 2023-12-13
• $4,376 — penalty dated 2023-12-13
• Medicare payment denial — starting 2024-08-30 for 11 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BEDFORD CARE CENTERS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MS