Bedford Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that resident's advance directives were accurately reflected for 3 residents in a final sample of 32 residents. (Resident identifiers are #18, #70 and #92.)Findings include:Interview on [DATE] with Staff E (Regional Clinical Nurse) revealed that the facility places a green dot on the spine of paper charts to indicate a Full Code status (meaning perform CPR (Cardiopulmonary resuscitation)). Resident #70 Review on [DATE] of Resident #70's electronic medical record revealed a resident demographic banner that indicated a code status of Full Code. Further review revealed a physician's order dated [DATE] for a Full Code. Review on [DATE] of Resident #70's paper chart revealed there was a green dot on the outside spine of the book. Further review revealed a green Full Code sheet and a Portable Do Not Attempt Resuscitation (P-DNR) Order form that was signed and dated by the provider on [DATE]. Review on [DATE] of Resident #70's…

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.

Based on interview and record review, it was determined that the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for individuals who required greater than 30 days of facilities services for 2 of 3 residents reviewed for PASARR in a final survey sample of 24. (Resident identifiers are #20 and #48.)Findings include:Resident #48 Review on 12/15/25 of Resident #48's medical record revealed an admission date of 1/10/25 and a diagnosis of Traumatic Brain Injury. Review on 12/15/25 of Resident #48's PASARR Level 1 screen form, dated 1/8/25, revealed Section 6. Exemption/Exclusion, Hospital Discharge Exemption was signed by a provider on 1/24/25. Further review of this section revealed .If the NF [Nursing Facility] stay is 30 days or longer, a new PASARR screen and resident review must be performed with in 40 calendar days of admission . Interview on 12/17/25 at approximately 8:23 a.m. with Staff J (Social Services) confirmed that Resident #48 had remained at the nursing facility past 30 days and a PASARR Level 1 screen had not been done within 40 calendar…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 3 closed records reviewed. (Resident identifier is #119.)Findings include:Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .Review on 12/16/25 of Resident #119's physician orders, revealed the following…

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.

Based on observation, interview, and record review, it was determined that the facility failed to store medications securely in accordance with professional standards for 1 of 2 units observed.Findings include:Observation on 12/15/25 at approximately 8:00 a.m. of the first floor nurses' station revealed the following medication cards laying on the counter for Resident #119:Diltiazem HCI Coated Beads 240 Milligrams (MG) with 6 capsules remaining.Eliquis Oral Tablet 5 MG with 14 tablets remaining.Lasix Oral Tablet 40 MG with 8 tablets remaining.Lasix Oral Tablet 40 MG with 1 tablet remaining.Lasix Oral Tablet 20 MG with 12 tablets remaining.Letrozole Oral tablets 2.5 MG with 6 tablets remaining.Pantoprazole Sodium Oral Tablet Delayed Release 40 MG with 6 capsules remaining.Potassium Chloride Extended Release Tablet 20 Milliequivalent (MEQ) with 13 tablets remaining.Potassium Chloride Extended Release Tablet 20 Milliequivalent (MEQ) with 12 tablets remaining.Sotalol HCI Oral Tablet 120 MG with 18 tablets remaining.Further observation revealed the following the nurses' station entrance…

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.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and standards for 1 of 1 resident reviewed for Transmission Based Precautions (TBP) and 1 of 1 resident reviewed for catheters. (Resident identifier are #2 and #114.)Findings include:Resident #114Observation on 12/15/25 at 9:57 a.m. at the 300's hallway revealed that Resident #114 had a contact precaution sign posted outside of the door.Interview on 12/15/25 at 9:57 a.m. with Staff H (Registered Nurse (RN)) revealed that Resident #114 was on contact precaution for a Clostridium Difficile (C-diff) infection. Review on 12/15/25 of Resident #114's care plan revealed a contact precautions for C-diff infection care plan, dated 12/15/25, with the following interventions: Place resident in a private room with contact precautions. Care equipment should be appropriately cleaned, disinfected or sterilized according to facility protocol. Further review revealed a C-diff infection care plan, dated 12/15/25, with an intervention to disinfect all equipment used…

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.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from a medication cart in 1 of 3 medication carts observed. Findings include: Observation on 10/1/24 at approximately 8:20 a.m. revealed a bottle of Latanoprost Ophthalmic Solution 0.005% with an open date of 8/9/24. Review on 10/1/24 of manufacturers instructions on package revealed: .Opened bottle may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 weeks . Interview on 10/1/24 at approximately 8:25 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings and that the above medication was expired and currently in use. Review on 10/3/2024 of facility policy titled, Medication Storage, revised 4/16/24 revealed: . 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our…

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.

Based on observation and interview, it was determined that the facility failed to ensure that food and dishware were stored in accordance to professional standards for food service safety for 1 of 1 kitchen observed. Findings include: Observation on 10/1/24 at approximately 8:30 a.m. with Staff H (Food Service Director) of the facility kitchen revealed a box of zucchini and yellow squash that were soft, covered with a clear slime-like substance, clusters of white fuzzy substance, and black discoloration that were stored in the kitchen walk-in refrigerator. Further observation revealed a stack of pre-sliced hard yellow cheese half covered with saran wrap with no date. Interview on 10/1/24 at approximately 8:30 a.m. with Staff H confirmed the above finding. Observation on 10/2/24 at approximately 8:40 a.m. with Staff H in the kitchen revealed a dietary aide stacked wet cups and stored them in a bin to air-dry. A few minutes later, another dietary aide took the same stack of wet cups and moved them to the main dining room for use. Interview on 10/2/24 at approximately 8:40 a.m. with…

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.

Based on observation, interview, and policy review, the facility failed to ensure dignity was maintained for 1 of 1 residents reviewed for dressing changes in a final sample of 18 residents (Resident identifier is #37). Findings include: Observation on 12/15/23 at approximately 10:10 a.m. of Resident #37's pressure ulcer dressing changes in his/her room with Staff B (Nurse Unit Manager) revealed that during the dressing change both the door and curtain remained open. A housekeeper entered the room during the dressing change. Interview on 12/15/23 at approximately 10:15 a.m. with Staff B confirmed the above findings. Review on 12/15/23 of the facility policy titled, Promoting/Maintaining Resident Dignity, Revised on 11/23/23 revealed: Compliance Guidance 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights 12. Maintain resident privacy

Based on interview, record review, and policy review, it was determined that the facility failed to notify the resident's physician when medications were unavailable for 1 resident in a final sample of 18 residents (Resident identifier is #281). Findings include: Resident #281 Review on 12/14/2023 of Resident #281 hospital discharge medication list, dated 12/6/2023, revealed an order for Clobazam (used for the treatment of seizures) 10 milligrams (mg) 1 tablet by mouth two times per day. Further review revealed that Resident #281 received Clobazam prior to leaving the hospital at 8:46 a.m. on 12/6/2023. Review on 12/14/2023 of Resident #281's December Medication Administration Record (MAR) revealed that Resident #281 did not receive a second dose of Clobazam on 12/6/23 and received one dose on 12/7/23 at 8:00 p.m. Review on 12/14/2023 of Resident #281's progress note, dated 12/6/2023, revealed that Clobazam had not been received from the pharmacy. Interview on 12/14/2023 at approximately 12:30 p.m. with Staff D (Director of Nursing) revealed that when a medication is unavailable, it…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physicians orders for 1 of 1 residents reviewed for general skin conditions in a final sample of 18 residents (Resident identifier is #6). Findings Include: Observation on 12/13/23 at approximately 9:30 a.m. of Resident #6's right hand revealed a mepiplex dressing dated 12/8/23. Review on 12/13/23 of Resident #6's medical record revealed the following physician's order: Skin tear top of right hand, cleanse with NS [normal saline] apply Vaseline, gauze, assure steri strips are intact then cover with Tegaderm, change QOD [every other day] and prn [as needed] every evening shift every other day, Start Date 12/3/23. Interview on 12/14/23 at approximately 1:15 p.m with Staff B (Nurse Unit Manager) confirmed the above findings. Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment.…

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.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secured for 2 of 3 medication carts observed and the facility failed to ensure that medications were labeled with open expiration dates for 1 of 3 medication carts and 1 of 1 medication room observed. Findings include: Overflow Medication Cart Observation on 12/13/23 at 8:15 a.m. with Staff G (Nurse Unit Manager) revealed that the nurse's station door was open. The Overflow Medication Cart was unlocked in the nurse's station. Further observation also revealed that the Overflow Medication Cart had resident's oral prescription medications, resident's prescription inhalers and Over-The-Counter (OTC) medications. Interview on 12/13/23 at approximately 8:15 a.m. with Staff G confirmed the above finding. Staff G stated that only nurses and Medication Nursing Assistants (MNAs) should have access to medications. Staff G also stated that staff other than the nurses and MNAs, such as providers, Licensed Nursing Assistants, and therapists have access to the nurse's…

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.

Based on observation, interview, and policy review it was determined that the facility failed to maintain a clean environment in the dishwashing area. Findings include: Main Kitchen Observation on 12/13/23 at 8:00 a.m. in the kitchen dishwashing area with Staff L (Dietary Director) revealed two fans that were on and one ceiling vent that had accumulated gray dust and grease debris. Interview on 12/13/23 at 8:05 a.m. with Staff L confirmed the above finding. Review on 12/15/23 of the FDA [Food and Drug Administration] Food Code, dated 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed . 4-602.13 Nonfood Contact Surfaces Nonfood contact surfaces or equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues . Review on 12/15/23 of facility policy titled, Sanitization, last revised November 2022, revealed: The food services area is maintained in a clean and sanitary manner.

Based on interview and record review, it was determined that the facility failed to secure a communication process was implemented that ensures that the needs of the resident were addressed for hospice services for 1 resident in a closed record sample of 4 residents (Resident identifier is #228). Findings include: Review on 12/14/23 of Resident #228's hospice notes, dated 10/19/23, revealed that there was a recommendation to increase the morning dose of methadone to 5 milligrams (mg) and this was reviewed with the facility unit manager. Review on 12/14/23 of Resident #228's hospice recommendation forms revealed the following: On 10/9/23, there was a hospice recommendation for Methadone [Opioid] 10 mg/ml [milligram/milliliter] to give 0.25 ml [2.5 mg] by mouth every 12 hours. Further review of the 10/9/23 hospice recommendation revealed the facility nurse and provider had signed the hospice recommendation. On 10/19/23, there was a hospice recommendation to increase Methadone 10 mg/ml to 5 mg (0.5 ml) by mouth every morning and keep same dose of 2.5 mg (0.25 ml) by mouth every…

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.