Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Hills Center during CMS and state inspections, most recent first.
A resident with a saddle pulmonary embolism was prescribed Apixaban to prevent blood clots. The resident received the correct dosage initially but did not receive any Apixaban from July 22 to August 29. This significant medication error was confirmed by the DON, who identified the lapse on August 28.
A facility failed to inform a resident and/or their representative about the risks and benefits of Zyprexa, an antipsychotic medication prescribed for delusions. The resident's medical record lacked documented consent or evidence of a discussion regarding the medication's risks and benefits, as confirmed by the Unit Manager. Facility policy mandates that staff inform residents or their representatives about the initiation, reason for use, and associated risks of psychotropic medications.
The facility did not remove expired medications from stock in one of its medication rooms. Two opened bottles of APLISOL, a Tuberculin Purified Protein Derivative, were found in the refrigerator with an expired use date. The Unit Manager confirmed the expired status, and the manufacturer's instructions indicated that vials in use for more than 30 days should be discarded. The facility's policy requires expired medications to be placed in a designated, secure location.
The facility failed to provide timely Medicare Non-Coverage Notices to two residents. One resident remained in the facility after Medicare services ended, but did not receive an ABN notice. Another resident was discharged home without receiving a NOMNC form. Staff confirmed these omissions.
The facility failed to ensure accurate MDS assessments for three residents. One resident's MDS indicated an unplanned discharge, while records showed a planned discharge. Two residents' MDS assessments incorrectly stated they were receiving hospice services, which was confirmed as inaccurate by the MDS Coordinator.
A resident experienced a significant medication error when a nurse used a U-100 syringe instead of a U-500 syringe to administer Humulin R U-500 insulin, resulting in an overdose. The resident received five times the prescribed dose on two occasions, leading to severe hypoglycemia and hospitalization. The manufacturer's instructions explicitly warn against transferring insulin from the pen to a syringe, highlighting the critical nature of the error.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident with a discharge diagnosis of a saddle pulmonary embolism was prescribed Apixaban, an anticoagulant medication, to prevent blood clots. The prescribed regimen was to take 10 mg twice daily for 7 days, followed by 5 mg twice daily. However, the resident received 10 mg of Apixaban from July 11 to July 18, and 5 mg from July 18 to July 22. Subsequently, the resident did not receive any Apixaban from July 22 to August 29. This lapse in medication administration was confirmed by the Director of Nursing during an interview, who acknowledged that the error was identified on August 28.
Failure to Inform Resident of Antipsychotic Medication Risks
Penalty
Summary
The facility failed to inform a resident and/or the resident's representative about the risks and benefits of antipsychotic medication, specifically Zyprexa, prescribed for delusions. The physician orders for Zyprexa, at dosages of 2.5 mg every afternoon and 5 mg every evening, were dated 11/9/23. However, upon review of the resident's medical record, there was no documented consent or evidence of a discussion regarding the medication's risks and benefits. This deficiency was confirmed during an interview with the Unit Manager. The facility's policy on psychotropic medication use requires staff to inform residents or their representatives about the initiation, reason for use, and associated risks of such medications.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to ensure that expired medications were removed from stock in one of the two medication rooms observed. During an observation, two opened multi-dose bottles of APLISOL, a Tuberculin Purified Protein Derivative, were found in the refrigerator of the medication room on the [NAME] Unit. These bottles were labeled with an open date of 6/20/24 and a do not use after date of 7/20/24, indicating they were expired. Staff A, the Unit Manager, confirmed these findings during an interview. The manufacturer's instructions for APLISOL state that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency. The facility's policy on the disposal of expired medications requires that all discontinued or outdated medications be placed in a designated, secure location solely for discontinued medications.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notification to residents and/or their representatives regarding the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) for two residents. Resident #110 was discharged from Medicare Services on June 10, 2024, but remained in the facility. The facility's records indicated that the last covered day of Medicare Part A Skilled Services for Resident #110 was June 10, 2024, and the discharge from Medicare Part A Services was initiated by the facility. However, the SNF ABN notice was not provided to Resident #110, as confirmed by Staff D, the Minimum Data Set Coordinator. Similarly, Resident #131 was discharged from Medicare Services on June 10, 2024, and subsequently discharged home. The facility's records showed that the last covered day of Medicare Part A Skilled Services for Resident #131 was also June 10, 2024, but the NOMNC form was not provided. Staff D confirmed the omission, and Staff E, the Director of Social Services, noted that Resident #131 had reached their baseline and no longer required skilled Medicare services. Staff C, the Administrator, acknowledged that the facility should have issued a NOMNC for Resident #131.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for three residents. For Resident #128, the MDS assessment indicated an unplanned discharge, while the discharge assessment showed a planned discharge to home. Staff B, the MDS Coordinator, confirmed the coding error. Resident #1's MDS assessment inaccurately indicated that the resident was receiving hospice services, despite no corresponding order or care plan in the medical record. Staff B confirmed this error as well. Similarly, Resident #62's MDS assessment incorrectly stated that the resident was receiving hospice services, which Staff B also confirmed was incorrect.
Insulin Overdose Due to Syringe Misuse
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a resident receiving an overdose of insulin. The error occurred when a registered nurse used a U-100 insulin syringe instead of a U-500 syringe to administer Humulin R U-500 insulin from the resident's insulin pen. This mistake led to the resident receiving five times the prescribed dose of insulin on two separate occasions. The manufacturer's instructions for Humulin R U-500 clearly state that the insulin should not be transferred from the pen into a syringe, as this can lead to severe overdoses and dangerously low blood sugar levels. As a result of the overdose, the resident experienced hypoglycemia, with blood glucose levels dropping to as low as 40 mg/dL. The resident became lethargic and was only arousable with repeated stimuli, necessitating the administration of insta glucose gel and subsequent transfer to the hospital for evaluation and treatment. The resident's medical records indicated several episodes of hypoglycemia overnight, confirming the severity of the medication error.
Removal Plan
- Updated the policy titled: Insulin
- Completed in-service education to all nurses on the administration of insulin with an insulin pen specific to Humulin R U-500
- Conducted competencies with all nurses on the administration of insulin with an insulin pen
- Monitoring insulin administration through weekly audits
- Reviewing these audits at quarterly Quality Assurance and Performance Improvement meetings
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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) |
|---|---|---|---|---|
| Ridgewood Center, Genesis Healthcare | 0.3 mi | ★★★★★ | 5 | 0 |
| Bedford Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 7 | 1 |
| Maple Leaf Health Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Mount Carmel Rehabilitation And Nursing Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Hanover Hill Health Care Center | 3.1 mi | ★★★★★ | 2 | 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.