Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Bedford Specialty Care during CMS and state inspections, most recent first.
Two residents' discontinued lorazepam tablets remained in the controlled substances drawer instead of being destroyed or returned to the pharmacy as required. An LPN discovered the medications during a check, and staff interviews confirmed that facility policy was not followed regarding the timely disposal of controlled substances.
A facility failed to include a wander guard in the care plan of a resident with severe cognitive impairment and high wandering risk. Despite wearing a wander guard daily, the care plan lacked documentation of this intervention. Staff interviews confirmed the oversight, contradicting the facility's policy requiring risk factors to be incorporated into care plans.
The facility failed to follow proper infection control practices for two residents with severe cognitive impairment. Staff did not perform hand hygiene between glove changes during personal care tasks, contaminating clean surfaces. The Director of Nursing confirmed that the facility's policy requires hand hygiene when moving from contaminated to clean areas and after glove removal.
The facility failed to perform ongoing infection control surveillance and appropriate hand hygiene during resident care. The Infection Preventionist confirmed that documentation had not been completed since 2019. Additionally, a CNA was observed performing improper hand hygiene while providing catheter care to a resident, contrary to facility policy.
The facility failed to notify the Long-Term Care Ombudsman of the discharge or transfer of two residents as required. One resident with renal failure and diabetes was transferred to the hospital and returned, but the transfer was not documented. Another resident with heart failure and diabetes was also transferred and returned, but this transfer was not documented either. The facility's policy mandates notification to the Ombudsman, which was confirmed by the Administrator.
The facility failed to provide the required bed-hold notice to residents or their representatives at the time of transfer to a hospital for two residents. Both residents were transferred and returned without documented confirmation that the bed-hold policy/authorization was communicated.
The facility failed to complete a significant change MDS within 14 days for a resident placed on hospice care. The resident, with severe cognitive impairment, was ordered to receive hospice services, but the MDS assessment was still in progress beyond the required timeframe. The MDS Coordinator was unaware of the 14-day requirement.
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week. The nursing schedule revealed no RN was scheduled to work on a specific date, which was confirmed by the Administrator.
The facility failed to report a VA eligible resident to the Iowa Department of Veterans Affairs within 30 days of admission. The resident, with moderately impaired cognition and significant medical needs, was not reported until several months after admission, despite having confirmed VA eligibility status.
Failure to Timely Destroy Discontinued Controlled Substances
Penalty
Summary
The facility failed to properly destroy discontinued controlled substances for two residents, as required by policy and regulation. For one resident with osteoporosis, anxiety disorder, and delirium, an order for lorazepam was discontinued, but 28 tablets remained in the controlled substances drawer. For another resident with Alzheimer's disease, depression, and anxiety, an order for lorazepam was also discontinued, yet 14 tablets remained in the drawer. Both residents had intact cognition according to their most recent assessments, though one had intermittent confusion and sundowning noted in the care plan. During an observation, an LPN removed all bubble packages from the double-locked controlled substances drawer and found the discontinued lorazepam tablets for both residents still present. Interviews with nursing staff and the DON confirmed that discontinued controlled substances should be destroyed or returned to the pharmacy immediately, and that the presence of these medications indicated a failure to follow this protocol. The facility's policy required waste or disposal of controlled medications to be done with a witness and proper documentation, which was not followed in these cases.
Failure to Include Wander Guard in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a high risk of wandering. The resident, diagnosed with Non-Alzheimer's Dementia and malnutrition, was assessed with a Brief Interview for Mental Status score indicating severe cognitive impairment. The Minimum Data Set (MDS) assessment noted the resident wore a wander guard daily, yet the care plan revised prior to the assessment did not include any mention of wandering risk or the use of a wander guard. An observation confirmed the resident was wearing a wander guard, and a wandering evaluation completed shortly after the care plan revision scored the resident as high risk for wandering. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the resident was considered unpredictable and should have had the wander guard included in the comprehensive care plan. The facility's policy on care plans, revised in December 2016, requires that care plan interventions incorporate risk factors associated with identified problems, which was not adhered to in this case.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to proper infection prevention practices, as observed in the care of two residents. For Resident #25, who has an indwelling catheter and severe cognitive impairment, staff members did not perform hand hygiene between glove changes during personal care tasks. Staff A and Staff C contaminated clean surfaces by touching them with soiled gloves and failed to wash their hands after removing gloves, which is against the facility's hand hygiene policy. This policy requires hand hygiene to be performed when moving from contaminated to clean areas and after glove removal. Similarly, for Resident #28, who has a colostomy and severe cognitive impairment, Staff A did not follow proper hand hygiene protocols. After removing the resident's colostomy bag and cleaning the area, Staff A used the same contaminated gloves to handle cleansing wipes, touching the package opening repeatedly. Staff A then removed the gloves and applied new ones without washing hands in between, contrary to the facility's expectations and hand hygiene policy. The Director of Nursing confirmed that the expectation was to perform hand hygiene after removing dirty gloves and before applying new ones.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to perform ongoing infection control surveillance and appropriate hand hygiene during resident care. On 5/01/24, it was observed that the facility's infection control surveillance documentation had not been completed since 2019. The Infection Preventionist (IP) confirmed that the facility only had documentation for 2019, despite the policy requiring ongoing surveillance for healthcare-associated infections and other significant infections. The Administrator acknowledged that infection control surveillance should follow CMS guidelines and facility policy. Additionally, on 4/30/24, a Certified Nurse Aide (Staff A) was observed performing improper hand hygiene while providing care to a resident. Staff A touched various surfaces and objects with gloved hands before cleansing the tip of the catheter port and emptying the catheter bag, which is against the facility's policy for catheter care. The Director of Nursing stated that the expectation is to gather supplies and prepare the area before washing hands, gloving, and performing the procedure to prevent catheter-associated urinary tract infections.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of the discharge or transfer of residents as required. Specifically, Resident #14, who had diagnoses of renal failure and diabetes, was transferred to the hospital on 1/7/24 and returned on 1/10/24, but this transfer was not documented in the facility's Notice of Transfer Form for January 2024. Similarly, Resident #22, who had diagnoses of heart failure and diabetes, was transferred to the hospital on 11/26/23 and returned on 12/4/23, but this transfer was not documented in the facility's Notice of Transfer Form for November 2023. The facility's policy, revised in March 2021, mandates that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The Administrator confirmed the expectation to notify the Ombudsman with transfers during an interview on 5/01/24.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide the required bed-hold notice to residents or their representatives at the time of transfer to a hospital for two residents. Resident #14, who had diagnoses of renal failure and diabetes, was transferred to the hospital and returned to the facility without documented confirmation that the bed-hold policy/authorization was communicated to the resident or their representative. The bed-hold policy/authorization form was completed, but there was no evidence of confirmation or details on the bed-hold rate provided. Similarly, Resident #77, who was admitted to the facility and then transferred to the hospital, did not receive the bed-hold information. Both the resident and his wife stated they did not recall receiving any bed-hold information. The bed-hold policy/authorization form for Resident #77 was also completed without documented confirmation that the information was communicated. The facility's policy required that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers, which was not adhered to in these cases.
Failure to Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) within 14 days for a resident placed on hospice care. Resident #18, who had a diagnosis of non-Alzheimer's dementia and severe cognitive impairment, was ordered to receive hospice services. However, the MDS assessment, which should have been completed within 14 days of the resident being placed on hospice, was still in progress beyond the required timeframe. The MDS Coordinator admitted to not knowing that a hospice significant change needed to be completed within 14 days from the date the resident was placed on hospice, leading to the deficiency.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. The facility, which reported a census of 26, did not have an RN scheduled to work on 4/14/24. This was confirmed by the Administrator during an interview on 5/01/24 at 4:30 PM, who acknowledged the lack of RN coverage on that date and stated that the facility follows federal regulations requiring RN coverage for eight hours a day.
Failure to Report VA Eligible Resident in a Timely Manner
Penalty
Summary
The facility failed to report a Veterans Affairs (VA) eligible resident to the Iowa Department of Veterans Affairs (IDVA) within 30 days of admission. Resident #6, who was admitted to the facility and had a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating moderately impaired cognition, was not reported in a timely manner. The resident had diagnoses including a fracture around the left knee prosthesis, acute respiratory failure, and non-Alzheimer's dementia, and required significant assistance with daily activities. The resident's VA eligibility was confirmed on 1/08/24, but the facility did not complete the necessary reporting until 5/01/24, well beyond the required 30-day period. The Administrator acknowledged the delay in reporting and confirmed that the VA eligibility check was not completed as per regulations. The Business Office Manager also confirmed having instructions for adding eligible residents to the IDVA eligibility list, but the process was not followed in this instance. This oversight was identified during a review of the VA Eligibility list and the resident's Electronic Health Record (EHR), which indicated Medicare part A as the primary payor and listed the resident's participation in Physical and Occupational Therapy (PT/OT).
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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.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lenox Care Center | 17.2 mi | ★★★★★ | 6 | 0 |
| Azria Health Clarinda | 17.3 mi | ★★★★★ | 0 | 0 |
| Worth County Convalescent Center | 20.9 mi | ★★★★★ | 9 | 0 |
| Good Samaritan - Villisca | 22.6 mi | ★★★★★ | 12 | 0 |
| Corning Specialty Care | 22.6 mi | ★★★★★ | 9 | 0 |
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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.