Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Care Center Of Mendenhall during CMS and state inspections, most recent first.
Two residents experienced significant medication errors due to failures in medication reconciliation and administration. One resident did not receive prescribed antibiotic therapy after a hospital discharge order was incorrectly transcribed, leading to missed doses and subsequent rehospitalization for wound infection. Another resident received a double dose of antihypertensive medications when two LPNs administered the same medications without proper EMAR documentation, requiring close monitoring and IV fluids.
The facility failed to follow infection prevention guidelines, including Enhanced Barrier Precautions (EBP) and hand hygiene practices. Clean and soiled items were improperly stored together, and staff did not adhere to EBP protocols during resident care. A CNA did not sanitize surfaces or change gloves appropriately, and an LPN failed to wear a gown during PEG tube care, risking infection transmission.
A facility failed to honor resident rights by not assisting a resident in getting out of bed as requested and discontinuing preferred nighttime snacks without proper communication. A resident, who is cognitively intact, expressed a desire to participate in activities but was left in bed. Additionally, several residents were not provided with sandwiches at night, as the Dietary Manager independently decided to stop preparing them without consulting the Nursing Home Administrator.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care. A resident's care plan lacked Enhanced Barrier Precautions (EBP) for a PEG tube, while another resident's care plan for a Foley catheter was not followed by a CNA. The DON confirmed these issues, and the LPN emphasized the importance of updated care plans. Both residents had specific medical conditions requiring these precautions.
A facility failed to obtain a physician's order for a resident using a seatbelt as an enabling device, which is required by professional standards. The resident, diagnosed with Parkinson's disease and dementia, had been using the seatbelt since December 2024 without proper documentation or ongoing assessment. The DON acknowledged the oversight, and the LPN admitted to a lack of documentation regarding monitoring the resident while using the seatbelt.
A resident with multiple diagnoses, including Vascular Dementia and moderately impaired cognition, sustained a third-degree burn after spilling hot coffee on himself due to the facility's failure to develop comprehensive care plan interventions. The resident was left unsupervised, and no care plan was in place to prevent such incidents or to manage the resident's use of chewing tobacco, which was against facility policy.
A resident with multiple diagnoses, including Diabetes Mellitus and Vascular Dementia, sustained a third-degree burn after spilling hot coffee on himself in the dining room. The facility failed to follow its policy on the safety of hot liquids, as coffee was served without lids and at temperatures as high as 167 degrees Fahrenheit. Residents were allowed to serve themselves coffee without adequate supervision, leading to the incident and placing others at risk.
A resident's right to self-determination was violated when a facility confiscated his chewing tobacco without notice, despite prior permission. The sudden enforcement of a tobacco-free policy caused the resident, who had a history of cognitive impairment and anxiety, significant distress. Confusion among staff about the policy led to inconsistent enforcement, exacerbating the resident's emotional turmoil.
Medication Reconciliation and Administration Errors Result in Missed Antibiotic Therapy and Duplicate Antihypertensive Dosing
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not accurately reconciling hospital discharge medications and not ensuring timely and accurate medication administration. For one resident with a principal diagnosis of surgical aftercare following digestive system surgery, the facility did not properly transcribe a hospital discharge order for doxycycline, an antibiotic prescribed for a surgical wound infection. Instead, the order was incorrectly entered as pyridoxine (Vitamin B6), resulting in the resident missing six doses of the prescribed antibiotic. This error was identified after the resident was rehospitalized for wound dehiscence and infection, with documentation confirming the medication error and the delay in appropriate treatment. Another resident with a diagnosis of hypertension experienced a medication error when two different LPNs administered the same morning dose of antihypertensive medications, Lisinopril and Metoprolol, resulting in the resident receiving double the prescribed dosage. The error occurred because the first nurse failed to document the administration in the electronic medication administration record (EMAR) after being called away for an emergency, and the second nurse, seeing no documentation, administered the medications again. The incident was discovered later that morning, and the resident required close monitoring and intravenous fluids as a result of the double dosing. Both incidents were attributed to failures in following facility policy regarding medication reconciliation and administration, including accurate transcription of orders, timely documentation in the EMAR, and ensuring the five rights of medication administration. The deficiencies directly affected two of four sampled residents, resulting in missed antibiotic therapy and duplicate antihypertensive dosing, with one resident requiring rehospitalization for wound complications.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention guidelines, specifically in the implementation of Enhanced Barrier Precautions (EBP) and hand hygiene practices. During the survey, it was observed that clean and soiled items were improperly stored together in a biohazard room, posing a risk of contamination. The Housekeeping Supervisor acknowledged the risk associated with storing clean items in the biohazard room due to limited storage space. In the case of Resident #31, a Certified Nursing Assistant (CNA) did not follow proper EBP protocols during foley catheter care. The CNA failed to sanitize the bedside table, use a protective barrier, or don a gown before providing care. Additionally, the CNA did not change gloves after touching potentially contaminated surfaces and placed soiled items on the floor, which could lead to cross-contamination. The CNA admitted to not following the correct procedures despite having received training on EBP. For Resident #13, a Licensed Practical Nurse (LPN) did not wear a gown while performing percutaneous endoscopic gastrostomy (PEG) tube site care, despite the presence of EBP signage indicating the need for such precautions. The LPN acknowledged the oversight and the potential risk of infection at the PEG tube site, especially given the resident's history of multidrug-resistant organism colonization. The Director of Nursing confirmed that the staff's failure to adhere to infection control guidelines could result in infection transmission among residents and staff.
Failure to Honor Resident Preferences and Rights
Penalty
Summary
The facility failed to honor resident rights by not allowing a resident to get out of bed as requested and not providing preferred snacks at bedtime. Resident #44, who is cognitively intact with a BIMS score of 14, expressed a desire to get out of bed to participate in activities such as Bingo. Despite her requests, the facility staff did not assist her in getting out of bed, leaving her in bed most of the time. The Director of Nursing (DON) acknowledged that Certified Nursing Assistants are supposed to ask residents daily if they want to get up, but this was not consistently done for Resident #44. Additionally, the facility did not provide sandwiches as preferred snacks at night for several residents, including Residents #26, #33, #40, and #41. During a Resident Council meeting, residents expressed concerns about not receiving sandwiches at night. The Activities Director confirmed that residents were not receiving sandwiches, and the Dietary Manager (DM) stated that she stopped preparing sandwiches due to receiving many back uneaten. The DM made this decision independently without consulting the Nursing Home Administrator (NHA) or the DON. The NHA was only informed of the decision to discontinue sandwiches after it had been implemented. The NHA stated that the decision should have been brought to his attention beforehand, as it was his responsibility to make such calls. The discontinuation of sandwiches was not communicated to the residents, leading to dissatisfaction and a failure to honor their preferences for nighttime snacks.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two residents, leading to deficiencies in care. For Resident #13, the care plan did not include Enhanced Barrier Precautions (EBP) related to the presence of a percutaneous endoscopic gastrostomy (PEG) tube, despite an active order requiring the use of gloves and a gown when providing care. The Director of Nursing (DON) confirmed the omission, and the Licensed Practical Nurse (LPN) responsible for updating care plans acknowledged the importance of comprehensive and updated care plans to guide staff in providing adequate care. For Resident #31, although the care plan included EBP related to the presence of a Foley catheter, a Certified Nursing Assistant (CNA) failed to follow the care plan by not donning a gown before providing catheter care. The CNA admitted to not following the care plan despite having received training on EBP. The DON reiterated the expectation that staff adhere to care plans, and the LPN emphasized the critical role of care plans in ensuring resident well-being. Both residents had specific medical conditions requiring these precautions, with Resident #13 having a PEG tube and Resident #31 having a Foley catheter due to neuromuscular dysfunction of the bladder.
Lack of Physician's Order for Enabling Device
Penalty
Summary
The facility failed to ensure that a resident using an enabling device, specifically a seatbelt, had a physician's order, which is a requirement as part of the professional standard of practice. This deficiency was identified for one resident who had been using the seatbelt since December 2024. During an interview, the Licensed Practical Nurse (LPN) admitted there was no documentation regarding the monitoring of the resident while using the seatbelt, although they usually check on her every 15 minutes. The Director of Nursing (DON) confirmed the absence of a physician's order for the seatbelt and acknowledged it as an oversight. The resident involved had been admitted to the facility in June 2024 with diagnoses of Parkinson's disease without dyskinesia and unspecified dementia. A quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment. Despite the resident's ability to self-release the seatbelt, there was no documentation of ongoing assessment regarding the use of the seatbelt, which was intended to help reduce falls. The DON noted that the issue was discussed with the Interdisciplinary Team (IDT) when the seatbelt was issued, but no further documentation was maintained to assess the resident's condition or the effectiveness of the seatbelt.
Failure to Develop Comprehensive Care Plans Leads to Resident Injury
Penalty
Summary
The facility failed to develop comprehensive care plan interventions for a resident, resulting in a third-degree burn. The resident, who had diagnoses including Diabetes Mellitus, Hemiplegia, Vascular Dementia, and moderately impaired cognition, sustained a burn to his left thigh after spilling hot coffee on himself. The incident occurred when the resident was left unsupervised with a cup of coffee, leading to the injury. Despite the resident's medical conditions and cognitive impairment, no care plan interventions were in place to prevent such incidents. Additionally, the facility did not have care plan interventions for the resident's use of chewing tobacco. The resident had been allowed to use chewing tobacco since admission, despite the facility's policy against it. The lack of a care plan for tobacco use meant there were no guidelines for staff to follow, potentially impacting the resident's care and safety. Interviews with facility staff, including the Administrator, LPN responsible for care plans, and the DON, confirmed the absence of necessary care plan interventions. The staff acknowledged the oversight and the importance of care plans in guiding resident care. The failure to implement these interventions placed the resident and others at risk of harm, as evidenced by the burn incident.
Removal Plan
- The coffee machine was taken out of service so that individuals cannot serve themselves coffee. Individual pots of coffee will be made and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit. Resident #1 will be served coffee at or below 140 degrees Fahrenheit.
- The root cause of the accident was identified as the hot liquid policy not being followed, along with the lack of proper supervision.
- Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving. This will serve as a record of temperatures of coffee being served.
- Training for all staff prior to working shifts was initiated by the staff development nurse and the Director of Nursing on the following topics: Safety and supervision of residents, Care Plans, Temperature logs for coffee, hot liquids policy. No staff will be allowed to work until they have received appropriate training.
- Updated the care plans for resident #1 and identified thirty-three residents that were at risk to include interventions to prevent burns.
- Weekly body audits were completed for all residents and there were no burns noted.
- Quality Assurance and Performance Improvement committee meeting was conducted and the issue was discussed including root cause and appropriate remedies. Attending the meeting: Medical Director, Administrator, Director of Nursing, Resident Care Coordinator/ Infection Preventionist, Dietary Manager, Social Worker, Business Office Manager, Staff Development Nurse, Minimum Data Set Nurse, Medical Records Clerk, Environmental Services Manager, Maintenance Director and the staff scheduler.
Inadequate Supervision Leads to Resident Burn from Hot Coffee
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a burn from hot coffee for one of the sampled residents, which had the potential to affect all residents who drink coffee in the dining room. The incident involved a resident with diagnoses including Diabetes Mellitus, Hemiplegia on the left side, Vascular Dementia, and moderately impaired cognition. The resident sustained a third-degree burn to his left thigh after spilling hot coffee on himself. The coffee was served without a lid, and the resident was left unsupervised in the dining room. Observations and interviews revealed that the facility's policy on the safety of hot liquids was not followed. The policy required hot liquids to be served at safe temperatures and with appropriate safety precautions, such as using lids on cups and providing supervision. However, the coffee machine in the dining room was accessible to residents at all times, and the coffee temperature was not monitored, resulting in coffee being served at temperatures as high as 167 degrees Fahrenheit. Staff interviews indicated that residents, including those with impairments, were allowed to serve themselves coffee without adequate supervision. The Director of Nursing confirmed that there were no interventions put in place to prevent further incidents after the resident received the burn. The coffee temperature had never been checked before or after the incident, and the coffee machine had been in the dining room for a long time without any temperature regulation. The facility's failure to implement safety measures and provide adequate supervision led to the resident's injury and placed other residents at risk of similar accidents.
Removal Plan
- The coffee machine was taken out of service so that individuals cannot serve themselves coffee. Individual pots of coffee will be made and temperatures of the pots will be monitored to ensure that the coffee served is at or below 140 degrees Fahrenheit.
- The root cause of the accident was identified as the hot liquid policy not being followed, along with the lack of proper supervision.
- Coffee Temperature logs were created to indicate the temperature of the beverage prior to serving.
- Training for all staff prior to working shifts was initiated by the staff development nurse and the Director of Nursing on topics including safety and supervision of residents, care plans, temperature logs for coffee, and the hot liquids policy. No staff will be allowed to work until they have received appropriate training.
- Updated the care plans for Resident #1 and identified thirty-three residents that were at risk to include interventions to prevent burns.
- Weekly body audits were completed for all residents and there were no burns noted.
- Quality Assurance and Performance Improvement committee meeting was conducted to discuss the issue including root cause and appropriate remedies.
Resident's Right to Self-Determination Violated by Tobacco Confiscation
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by confiscating his chewing tobacco without notice, despite having previously granted him permission to use it. This action was contrary to the facility's policy, which prohibited tobacco use but had made an exception for the resident due to low census at the time of his admission. The resident, who had been using chewing tobacco for most of his life, was deeply distressed by the sudden enforcement of the tobacco-free policy, leading to emotional outbursts and fear of further confiscation. The incident began when the facility's Director of Nursing (DON) enforced the tobacco-free policy without communicating the decision to the resident's family, who had been given time to devise a plan to wean him off tobacco. The resident's family had been informed by the Administrator that the policy would be strictly enforced, but they were not prepared for the immediate removal of the tobacco. This lack of communication led to confusion among staff, with some allowing the resident to use tobacco and others adhering strictly to the policy, causing further distress to the resident. The resident, who had a history of Type 2 Diabetes Mellitus, Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, was particularly vulnerable to the emotional turmoil caused by the sudden policy enforcement. His cognitive impairment, as indicated by a BIMS score of 11, further complicated the situation, as he struggled to understand the inconsistency in staff responses. The facility's failure to communicate effectively and consistently enforce the policy resulted in significant emotional distress for the resident, as evidenced by his crying, screaming, and refusal of care during the period his tobacco was confiscated.
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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 Mendenhall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Nursing Center | 10.5 mi | ★★★★★ | 1 | 0 |
| Briar Hill Rest Home | 20.5 mi | ★★★★★ | 5 | 0 |
| Ms Care Center Of Raleigh | 21.5 mi | ★★★★★ | 0 | 0 |
| Jnh-jaquith Inn | 21.7 mi | ★★★★★ | 7 | 0 |
| Jnh-jefferson Inn | 21.7 mi | ★★★★★ | 8 | 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.