Below average — CMS composite of the measures below.
The next survey window likely opens 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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Initiate CPR for a Full-Code Resident: An RN pronounced a resident dead after being told by an LPN that the resident had passed away, even though the resident was full code. The LPN found the resident unresponsive, cold, and stiff, checked the chart, and then searched online about when not to start CPR before calling the on-call nurse. CPR was not initiated in accordance with the facility policy and AHA guidance.
Advance directive and code status documentation was inconsistent for three residents. One resident had Full Code documented in the EMR and paper chart, but also had a signed P-DNR form in the chart; two other residents had DNR orders and EMR banners, while their care plans listed Full Code. Staff confirmed the mismatched code status documentation.
PASARR Screening Not Completed Within Required Timeframe: The facility failed to complete required PASARR Level I screening for two residents who stayed beyond the expected short-term NF stay. One resident had TBI and remained past 30 days after a hospital discharge exemption was signed, and another resident admitted with psychosis later had mild dementia added to the dx list; in both cases, staff confirmed that a new PASARR screen and resident review were not completed within 40 calendar days of admission.
A resident with insulin orders had a sliding-scale dose given for a CBG over 351, a scheduled 15-unit dose held, and another sliding-scale dose given later for a blood sugar of 469. Staff documented the held dose and the resident's poor intake and drowsiness, but there was no documentation of provider notification for the high CBG, no entry in the provider communication book, and an LPN confirmed the evening insulin was given without notifying a provider.
Medications for a resident were found on the counter at the nurses' station, including several tablets and capsules with remaining doses. The station entrance was open to the common area with no staff present, and an LPN confirmed that medications should be kept locked in a medication cart or medication room.
Failure to follow infection control practices involved a resident on contact precautions for C-diff and another resident with an indwelling urinary catheter. A RN carried a glucometer and the resident’s inhaler out of the room after care, disinfected the glucometer with a wipe that was not indicated for C-diff, and stored the inhaler in the med cart without disinfection. Separately, a resident’s urinary drainage bag was observed resting on the floor, contrary to catheter maintenance guidance.
A survey revealed that a medication cart contained an expired bottle of Latanoprost Ophthalmic Solution, which had been opened beyond the manufacturer's recommended storage period. An LPN confirmed the medication was expired and still in use. The facility's policy requires routine inspections for outdated medications, which are to be destroyed according to their policy.
The facility failed to store and handle food and dishware according to professional standards. Spoiled zucchini and squash were found in the refrigerator, and cheese was improperly wrapped without a date. Wet cups were stacked to air-dry and then used in the dining room. The Food Service Director confirmed these practices, which did not align with the facility's food safety policy or the FDA 2017 Food Code.
The facility did not employ a qualified Infection Preventionist with completed specialized training, despite being responsible for the infection prevention and control program for 86 residents. Staff D, the full-time Infection Preventionist, had not completed the required training, and Staff E, who assisted, also lacked specialized education.
Failure to Initiate CPR for a Full-Code Resident
Penalty
Summary
The facility failed to provide CPR in accordance with AHA guidelines and its own policy for one resident who was a full code. Staff A, an RN, documented that Staff B, an LPN, told them the resident had passed away and needed to be pronounced. Staff A then assessed the resident, found no blood pressure, no apical pulse, no respirations, and fixed pupils, and pronounced the resident dead at 6:40 a.m. Staff A later documented that immediately after pronouncing the resident, they learned the resident was full code and CPR had been initiated, with 911 called. Staff B stated they entered the resident’s room between 5:00 a.m. and 5:30 a.m. to give morning medication and found the resident unresponsive, with no vital signs and cold and stiff to the touch. Staff B checked the chart, saw the resident was full code, and then performed an internet search about when not to start CPR before calling the on-call nurse and reporting that the resident had passed away and needed to be pronounced. The on-call nurse stated they were informed early that morning that the resident had passed away and needed to be pronounced, and said they were not aware the resident was full code at the time of the call. The facility policy required staff to provide basic life support, including CPR, prior to EMS arrival unless there were advance directives, a DNR order, or obvious signs of clinical death.
Advance Directive and Code Status Documentation Inconsistencies
Penalty
Summary
The facility failed to ensure that residents' advance directives were accurately reflected in the medical record for 3 residents in a sample of 32. Review of the records for Residents #70, #18, and #92 showed mismatches between code status documentation in different parts of the chart. For Resident #70, the electronic medical record showed Full Code in the demographic banner and a physician order for Full Code, while the paper chart had a green Full Code dot and sheet along with a signed Portable Do Not Attempt Resuscitation (P-DNR) form. Staff A stated CPR would be performed based on the electronic record, and Staff F later confirmed the resident's code status was DNR and that the physician's order had not been updated. For Resident #18, the electronic medical record showed a physician order and banner indicating DNR, but the care plan listed the resident as Full Code. For Resident #92, the electronic medical record also showed DNR in the physician order and banner, while the care plan listed Full Code. Staff I confirmed the findings for both residents. The facility policy stated that decisions regarding the resident's choices would be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.
PASARR Screening Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to complete PASARR screening for residents who required more than 30 days of nursing facility services. For Resident #48, the record showed an admission date of 1/10/25 and a diagnosis of traumatic brain injury. A PASARR Level 1 screen dated 1/8/25 included a hospital discharge exemption signed by a provider on 1/24/25, but the record also stated that if the nursing facility stay was 30 days or longer, a new PASARR screen and resident review had to be performed within 40 calendar days of admission. Staff J from Social Services confirmed that Resident #48 remained in the facility past 30 days and that a PASARR Level 1 screen had not been completed within 40 calendar days of admission. For Resident #20, the record showed admission to the facility on 1/24/25 with a diagnosis of unspecific psychosis not due to a substance or known physiological condition, and a later diagnosis of mild dementia with mood disturbance added on 4/16/25. The PASARR Level I screen dated 1/24/25 indicated no suspected mental illness, no intellectual disability/developmental disability, no related condition, and no undiagnosed condition. The form also did not have hospital discharge checked, and a physician signed on 1/24/25 certifying that the resident would require less than 30 days of nursing facility services. The record further stated that if the stay was 30 days or longer, a new PASARR screen and resident review had to be performed within 40 calendar days of admission, and Staff D, the Administrator, confirmed that Resident #20 did not have a Level I PASARR completed within 40 days of admission.
Failure to Follow Insulin Orders and Notify Provider
Penalty
Summary
The facility failed to follow physician orders for Resident #119 by not administering insulin as ordered and by not documenting required provider notification. The resident had orders for Insulin Lispro sliding scale coverage, including notification of the provider for a capillary blood glucose over 351, and a scheduled dose of 15 units at 4:30 p.m. On 11/30/25, the MAR showed 10 units of sliding scale Insulin Lispro given at 11:30 a.m. for a CBG of 363, the scheduled 15-unit 4:30 p.m. dose documented as held, 0 units given at 4:30 p.m. for a blood sugar of 121, and 10 units given at 9:00 p.m. for a blood sugar of 469. Progress notes showed Staff L documented holding the 15-unit dose per nursing judgment for a CBG of 80 and no meal consumed, and later noted the resident was drowsy, resting in bed, refusing food, and that CBGs varied from high end of normal to 60. However, there was no documentation of provider notification for the CBG over 351, no entry in the provider communication book for the resident's CBGs that day, and Staff B confirmed giving the 10 units at 9:00 p.m. without notifying a provider. The facility policy required medications to be administered as ordered and any refusals or held medications to be reported and documented.
Medications Left Unsecured at Nurses' Station
Penalty
Summary
The facility failed to store medications securely in accordance with accepted professional principles for 1 of 2 units observed. During observation on 12/15/25 at approximately 8:00 a.m., medication cards for Resident #119 were found laying on the counter at the first floor nurses' station, including Diltiazem HCI Coated Beads 240 MG, Eliquis 5 MG, Lasix 40 MG and 20 MG, Letrozole 2.5 MG, Pantoprazole Sodium 40 MG, Potassium Chloride Extended Release 20 MEQ, and Sotalol HCI 120 MG, with varying quantities remaining in each card. Further observation showed the nurses' station entrance had no door and was open to the adjacent common area where residents were sitting, and there were no staff in or near the nurses' station. Review of the facility's Medication Storage policy stated that all drugs and biologicals must be stored in locked compartments and that only authorized personnel may have access to the keys. During interview at approximately 8:10 a.m., Staff I, an LPN, confirmed that medications should be locked in a medication cart or medication room.
Failure to Follow Infection Control Practices for Contact Precautions and Catheter Care
Penalty
Summary
The facility failed to implement infection control policies and standards for a resident on Transmission Based Precautions for C-diff and for a resident with an indwelling urinary catheter. Resident #114 had a contact precaution sign posted outside the room, and staff confirmed the resident was on contact precautions for a C-diff infection. The resident’s care plan directed staff to place the resident in a private room with contact precautions and to disinfect all equipment used before it left the room. During observation, a RN performed a fingerstick blood glucose test on Resident #114 while wearing a protective gown and gloves, then exited the room carrying a tray with the glucometer and the resident’s inhaler. The RN disinfected the glucometer at the medication cart in the hallway using a Super Sani-Cloth Germicidal Wipe and stored it in the cart, but the resident’s inhaler was stored in the medication cart without being disinfected. The RN confirmed the observation. Review of the wipe manufacturer’s instructions showed it did not indicate efficacy against C-diff, and the facility policy required noncritical resident-care equipment to be cleaned and disinfected according to manufacturer instructions with an EPA-registered disinfectant after use. Resident #2 had an indwelling urinary catheter for obstructive and reflux uropathy, and observations on multiple occasions showed the urinary drainage bag resting on the floor in the resident’s room. Staff confirmed the drainage bag was on the floor, and the infection preventionist stated that the urinary drainage bag should not be on the floor. The facility policy required catheter care in accordance with current professional standards, and CDC guidance stated to keep the collecting bag below the level of the bladder at all times and not to rest the bag on the floor.
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure the removal of expired medications from a medication cart, as observed during a survey. On October 1, 2024, at approximately 8:20 a.m., a bottle of Latanoprost Ophthalmic Solution 0.005% was found on a medication cart with an open date of August 9, 2024. According to the manufacturer's instructions, the opened bottle should be stored at room temperature for no more than six weeks, indicating that the medication was expired. This finding was confirmed by a Licensed Practical Nurse during an interview at approximately 8:25 a.m. on the same day. A review of the facility's policy on medication storage, revised on April 16, 2024, stated that the pharmacy and medication rooms are routinely inspected by a consultant pharmacist for outdated medications, which are to be destroyed according to the facility's policy on the destruction of unused drugs.
Improper Food and Dishware Storage in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper storage and handling of food and dishware in accordance with professional standards for food service safety. During an observation of the facility's kitchen, a box of zucchini and yellow squash was found in the walk-in refrigerator, exhibiting signs of spoilage such as softness, a clear slime-like substance, clusters of white fuzzy substance, and black discoloration. Additionally, a stack of pre-sliced hard yellow cheese was found half-covered with saran wrap and lacked a date label. These findings were confirmed by the Food Service Director, Staff H, during the observation. Further observations revealed improper handling of dishware, where a dietary aide was seen stacking wet cups to air-dry in a bin. Shortly after, another dietary aide used the same wet cups in the main dining room. Staff H confirmed the practice of stacking wet cups to air-dry and was unable to provide a facility policy on the storage and drying of dishware. A review of the facility's policy on food safety requirements highlighted the need for proper labeling, dating, and storage of refrigerated food, which was not adhered to in this instance. The FDA 2017 Food Code also emphasizes the need for food to be stored in clean, dry locations and for equipment and utensils to be adequately air-dried before use, which was not followed in the facility's practices.
Inadequate Infection Preventionist Training
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist who had completed specialized training in infection prevention and control, despite being responsible for the infection prevention and control program for a census of 86 residents. Staff D, who was designated as the full-time Infection Preventionist since January 2024, had not completed the specialized training that began in September 2023. Additionally, Staff E, a Registered Nurse assisting with the infection control and prevention program, also lacked specialized education in Infection Prevention. This deficiency was identified through interviews and record reviews conducted on October 2, 2024.
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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) |
|---|---|---|---|---|
| Bedford Hills Center | 1 mi | ★★★★★ | 2 | 0 |
| Ridgewood Center, Genesis Healthcare | 1.2 mi | ★★★★★ | 5 | 0 |
| Maple Leaf Health Care Center | 3 mi | ★★★★★ | 2 | 0 |
| Courville At Manchester | 3.1 mi | ★★★★★ | 12 | 1 |
| Mount Carmel Rehabilitation And Nursing Center | 3.1 mi | ★★★★★ | 0 | 0 |
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