Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Post Acute during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not notify the LTC ombudsman of hospital transfers for five residents. The residents had varied conditions including HF, pneumonia, respiratory failure, a feeding tube, cerebrovascular disease, diabetes, dementia, falls, and difficulty breathing. Events included low O2 sats, a feeding tube dislodgement, numbness spreading to the shoulder, hypoglycemia with unresponsiveness, a fall with bleeding, and respiratory distress. The DON confirmed there was no documented evidence of ombudsman notification for these transfers.
Failure to maintain a safe environment and provide needed assistive devices: two residents were found with unmet safety needs. One resident with dementia and epilepsy was sitting in a recliner, and staff confirmed no recliner safety assessment had ever been done. Another resident had an air mattress ordered after a fall with skin tears, but there was no documented re-assessment of the mattress. Two residents were also transported in wheelchairs without leg rests/footrests, and staff confirmed the devices should have been in place.
Failure to obtain informed consent for psychotropic medication changes. Two residents with dementia and other psychiatric diagnoses received increases in psychotropic meds, including an antidepressant, an anxiolytic, and an antipsychotic, but the clinical record had no documented evidence that the resident representative was informed in advance of the risks and benefits or treatment alternatives before the dose changes.
Incorrect MDS Coding for Antibiotic Use: Two residents had MDS assessments that failed to code antibiotic use in Section N0415F1 even though MARs showed antibiotic treatment during the look-back period. One resident received a topical cream containing Nystatin/Silvadene for sacral wound care, and another received Augmentin for cellulitis; the NHA confirmed the MDS coding was incorrect.
Staff failed to follow a physician order to apply tubi-grips for a resident with edema, as the compression garments were observed unused on the overbed table while the resident sat with bandaged lower legs. Staff also failed to send a caregiver with a severely cognitively impaired, non-verbal resident with aphasia to a neurology appointment as ordered, and the physician could not assess the resident because no attendant was present.
Medication labeling was not consistent with current orders for two residents, and an opened multi-dose vial in the med room was left undated. One resident had oxycodone doses signed out from the wrong card despite routine and PRN orders, while another resident’s lorazepam card label did not match the current order. Staff also observed an opened Tubersol vial in the fridge without the date it was opened.
Failure to provide ordered eating assistance: A resident with moderate cognitive impairment who needed staff supervision with eating was supposed to receive all foods in separate bowls at each meal. During lunch, the resident was observed eating in bed with food served on a regular plate instead of separate bowls, and an LPN confirmed the meal ticket called for separate bowls.
The facility’s QAPI committee failed to correct recurring deficiencies and maintain compliance with requirements for quality of care, a safe environment free from accident hazards, and storage and labeling of medications. Prior plans of correction included audits and reporting results to the QAPI committee, but the current survey found repeated deficiencies under F684, F689, and F761.
Improper hand hygiene was observed during medication administration when an LPN used bare hands to remove a pill from a cup, broke it in half, and gave it to a resident. The facility policy required infection control procedures, including hand sanitization, and both the LPN and DON confirmed the action was improper.
Failure to Offer Influenza and Pneumococcal Vaccines: Facility records showed that several residents were not offered influenza and/or pneumococcal vaccines as required by policy. MDS assessments documented that one resident did not receive the flu shot because it was not offered, another cognitively impaired resident was not offered either the flu or pneumonia vaccine, a third resident’s pneumococcal vaccine was not up to date and was not offered, and a fourth resident did not receive the flu shot because it was not offered. The NHA confirmed that these residents should have been offered the vaccines.
Failure to document the COVID-19 vaccine offer for a resident. A quarterly MDS showed the resident was cognitively impaired and had not been offered influenza or pneumonia vaccines, and the clinical record contained no immunization or declination documentation for COVID-19. The NHA stated the resident was not offered the COVID vaccine and should have been.
Failure to Provide Required QAPI Training to Nurse Aides: Five of five nurse aides reviewed did not complete annual QAPI education. Personnel records and continuing education transcripts showed no QAPI training for each aide, and the NHA confirmed the missing training during interview. The job description required staff to complete assigned education and training as required by law or regulation.
A resident with parkinsonism, who was cognitively intact, and their family raised concerns about staff providing drinking water from a shared bathroom sink. Although the concern was reported to staff and management, it was not documented in grievance logs or investigated according to facility policy. The DON did not consider the issue a grievance, and staff did not receive clear instructions on where to obtain water for the resident.
A resident with cognitive impairment and a history of falls was not provided with the prescribed fall prevention intervention of non-skid socks, as documented in the care plan. Despite the care plan update after a previous fall, the resident was found on the floor following another fall, and staff confirmed the intervention was not in place at the time.
Three residents with significant medical needs, including cognitive impairment, pressure ulcers, Parkinson's, stroke, and contractures, were provided with air mattresses without documented safety assessments. Clinical record reviews, observations, and DON interviews confirmed that no safety evaluations were completed prior to the use of air mattresses for these residents.
A nurse left a laptop displaying a resident's MAR open and unattended on a medication cart in the hallway, making confidential medical information visible to unauthorized individuals. Both the nurse and the DON confirmed this action did not comply with facility policy regarding resident privacy.
The facility did not ensure that the licenses of two nurses were verified with the State Board of Nursing and failed to complete a Nurse Aide Registry check for one nurse aide before employment, as confirmed by personnel file reviews and staff interviews. Required verifications were not documented prior to staff start dates, contrary to facility policy.
A resident who was cognitively intact and at risk for constipation did not receive all required interventions according to the facility's bowel protocol and physician orders. Despite no bowel movement for six days, only Milk of Magnesia was administered, with no documentation that a Dulcolax suppository or saline enema was given as required. The DON confirmed the protocol was not followed.
A resident with cognitive impairment and a back fracture did not receive a physician-recommended TLSO brace after hospital discharge. The facility was unable to obtain the brace from suppliers, and although therapy staff could have purchased it, they were told not to proceed. The resident's family intended to obtain the brace through a specialist but did not follow through, resulting in the resident never receiving the brace and experiencing a prolonged delay in physical therapy.
A resident with cognitive impairment and multiple medical conditions had several doses of oxycodone-acetaminophen signed out on the controlled drug record, but there was no documentation on the MAR to confirm administration. The DON confirmed the lack of required documentation for these controlled medication doses.
A resident with cognitive impairment and dementia received PRN Ativan for anxiety on several occasions without documented attempts at non-pharmacological interventions beforehand, contrary to facility policy and regulatory requirements. The DON confirmed that these interventions should have been tried prior to medication administration.
A medication error rate above 5% was identified when a nurse crushed an extended-release opioid tablet and failed to instruct a resident to rinse and spit after using a Dulera inhaler, both actions contrary to manufacturer guidelines. The errors were confirmed by the nurse and DON, and involved a resident with cognitive impairment and multiple medical conditions.
A registered nurse left a medication cart unlocked and unattended in a hallway while administering medications to a resident, contrary to facility policy requiring carts to be locked when out of sight. Both the nurse and the DON confirmed the cart should have been secured.
A resident with a nephrostomy tube and renal insufficiency experienced a change in condition, including dark red drainage and pain. Nursing staff notified supervisors and placed a call to the tele-health physician, but did not follow facility policy to escalate contact when there was no timely response. The physician returned the call over an hour later, after the resident's family had already arranged hospital transfer.
The facility was found to have unsanitary food service conditions due to a thick accumulation of dust on a vent above shelves where clean dishes and utensils were stored. This was observed during kitchen inspections and confirmed by the Director of Dining Services.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues with MDS assessments, care plan development and timing, medication storage and labeling, and food service operations. Despite developing plans of correction involving audits, the committee was ineffective in ensuring compliance with regulations.
The facility failed to maintain the dignity of three residents with indwelling urinary catheters by not covering their urinary drainage bags, as required by facility policy. Observations revealed that a resident in a wheelchair and another in bed had uncovered bags, visible to others. Interviews with nursing staff and the administrator confirmed the lack of privacy covers, violating the policy.
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization. Two residents were transferred to the hospital without documented evidence of written notice to their responsible parties. The Director of Nursing confirmed the lack of compliance with notification requirements.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS did not reflect the administration of an antiplatelet medication, despite physician orders and MAR records confirming its use. Another resident's discharge status was incorrectly coded as a hospital transfer, while nursing notes confirmed a discharge home. These errors were confirmed by the DON.
The facility failed to develop comprehensive care plans with specific interventions for several residents, including those with MDRO, tracheostomies, feeding tubes, and PICC lines. Despite being on Enhanced Barrier Precautions, these residents lacked individualized care plans, as confirmed by the DON.
A facility failed to update a resident's care plan to reflect the use of a foley catheter instead of urinary incontinence. Despite a physician's order for a foley catheter, the care plan inaccurately indicated urinary incontinence. Observations confirmed the resident had a urinary drainage bag, and the DON acknowledged the care plan was not revised.
A facility failed to complete a discharge summary for a resident, including a recapitulation of the resident's stay. Although discharge instructions and medications were provided to the resident and their son, there was no documented evidence of a completed discharge summary three months after the discharge, as confirmed by the Medical Records Coordinator.
A facility failed to obtain a physician's order for a urinary catheter for a resident admitted with urinary retention. The resident had a foley catheter in place upon arrival, but there was no documented physician's order from admission until a week later. The care plan noted the need for the catheter, and the DON confirmed the oversight.
The facility did not complete annual performance evaluations for two nurse aides by their due dates. Evaluations for these aides were overdue, and there was no documented evidence of completion. This was confirmed by the Nursing Home Administrator.
A facility failed to label a multi-dose container of Latanoprost Ophthalmic Solution with the date it was opened, as observed in one medication cart. The manufacturer's instructions require the bottle to be stored at room temperature for six weeks once opened, but there was no evidence of when it was opened. An LPN and the DON confirmed the oversight, which violated the facility's medication storage policy.
The facility failed to obtain necessary hospice documentation for two residents receiving hospice care. One resident with end-stage bladder cancer lacked the Hospice Certification of Terminal Illness in their record, while another resident with dementia did not have the Hospice Benefit of Election form documented until it was faxed by the hospice provider. Interviews confirmed the absence of these documents, indicating non-compliance with facility policy.
A facility failed to follow infection control guidelines for a resident with a feeding tube and tracheostomy. Staff did not wear gowns during high-contact care activities, despite Enhanced Barrier Precautions being in place. Interviews confirmed the need for both gloves and gowns, highlighting a lapse in adherence to infection control policies.
The facility failed to provide three nurse aides with the required 12 hours of annual in-service training. A review of records and staff interviews confirmed the absence of documentation for the necessary training hours.
The facility failed to follow physician orders for two residents. One resident with dementia was not properly monitored after a fall, as neurological checks and oxygen saturation levels were not documented. Another resident with endocarditis was not weighed daily as ordered, which was necessary to determine the need for diuretic medication. The DON confirmed these deficiencies.
The facility did not follow its grievance policies, failing to log and investigate grievances for two residents. A resident's concern about staff availability at night was not documented or investigated, and another resident's complaint about call bell response times and pain medication was not thoroughly investigated or documented.
A facility failed to update a resident's care plan to reflect their current mobility status. Despite a nursing note indicating the resident was ambulating independently, the care plan still required a mechanical lift for transfers. Observations confirmed the resident's independent mobility, and the DON acknowledged the care plan should have been updated.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers for five residents reviewed: Residents 1, 6, 9, 65, and 75. Facility policy dated January 7, 2026, stated that residents or their representatives are to be notified in writing of an impending transfer or discharge, and that a copy of the notice is sent to the State Long-Term Care Ombudsman. The policy also stated that when a resident is sent emergently to an acute care setting, it is considered a transfer and notice is provided to the resident and representative as soon as practicable before the transfer and to the LTC ombudsman when practicable. Resident 1 was cognitively intact, required assistance with some daily care needs, and had diagnoses including heart failure, pneumonia, and respiratory failure; after increased shortness of breath and low oxygen saturation, the physician was notified and the resident was sent to the hospital. Resident 6 was cognitively impaired, dependent on staff for all daily care needs, and had a feeding tube; when the feeding tube came out, she was sent to the hospital. Resident 9 was cognitively impaired, required assistance with daily care needs, and had diagnoses including cerebrovascular disease and diabetes; she was sent to the hospital after numbness spread from her left hand to her shoulder during a doctor appointment and again after an episode of low blood sugar with unresponsiveness and labored breathing. Resident 65 was cognitively impaired, required assistance with daily care needs, had recent falls and dementia; after sliding out of a chair and later having a skin tear that bled through the dressing, the physician ordered hospital evaluation. Resident 75 was cognitively intact and was sent to the hospital for difficulty breathing and admitted. The DON confirmed that there was no documented evidence that the ombudsman was notified of these hospital transfers and stated that as of June 15, 2026, the facility had not been notifying the ombudsman of resident hospital transfers.
Failure to Maintain Safe Environment and Provide Needed Assistive Devices
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible for two residents. Resident 2’s quarterly MDS dated April 2, 2026 showed mild cognitive impairment, need for staff assistance with daily care, and diagnoses of dementia and epilepsy. On June 17, 2026, Resident 2 was observed sitting in a recliner watching television. The Director of Rehabilitation stated that the facility had never done a recliner safety assessment on residents, and the Nursing Home Administrator confirmed that no recliner safety assessment was performed. The facility also failed to ensure that residents received assistance devices to prevent accidents for two residents. Resident 37’s quarterly MDS dated February 26, 2026 showed cognitive intactness, need for staff assistance with daily care, and a pressure ulcer; physician orders dated February 13, 2026 included use of an air mattress. After Resident 37 fell from bed on February 20, 2026 and sustained skin tears to the left arm, right elbow, and left knee, there was no documented evidence that the air mattress was re-assessed for safety. Resident 15’s comprehensive MDS dated May 8, 2026 showed cognitive impairment, wheelchair use for transport, and dementia; on June 14, 2026, the resident was observed being pushed in a wheelchair without leg rests, and Nurse Aide 3 confirmed the leg rests should have been applied before transport. Resident 53’s comprehensive MDS dated June 10, 2026 showed cognitive impairment, extensive assistance needs for transfers and locomotion, muscle weakness, and gait abnormality; on June 14, 2026, the resident was observed being pushed in a wheelchair without footrests, with her feet hanging down and able to touch the floor, and Nurse Aide 4 confirmed the wheelchair should have had leg rests to prevent injury during transport.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications and the treatment alternatives before initiating or increasing psychotropic medications for two residents. Facility policy dated January 7, 2025 stated that the resident or resident representative has the right to be informed in advance of the risks and benefits of proposed care, treatment alternatives, and treatment options, and that informed consent must be obtained and documented before psychotropic medication use, including for dosage increases. One resident had diagnoses including dementia, anxiety, and depression, was cognitively impaired, dependent on staff for daily care needs, and received psychotropic medications. Physician orders showed Paxil was started and later increased, and Valium was ordered for worsening behaviors related to anxiety disorder. There was no documented evidence that the resident representative was informed in advance of the risks and benefits and treatment alternatives before the increased dosages of Paxil and Valium. Another resident, who was cognitively impaired, required staff assistance for daily care needs, and had diagnoses including dementia, anxiety, and depression, had Seroquel increased for behavioral and psychological symptoms of dementia. There was no documented evidence that the resident representative was informed in advance of the risks and benefits and treatment alternatives before the increased dosage of Seroquel.
Incorrect MDS Coding for Antibiotic Use
Penalty
Summary
The facility failed to complete accurate MDS assessments for two residents by not coding Section N0415F1 for antibiotic medications when antibiotics were administered during the seven-day look-back period. For one resident, physician orders included daily and evening application of a 2% lidocaine/Nystatin/Silvadene/20% zinc topical cream for sacral wound care, and the MAR showed the cream was administered on multiple days in May 2026; however, the quarterly MDS dated May 14, 2026 did not code antibiotic medication use in Section N0415F1. The RAI User’s Manual stated that Section N0415F1 was to be coded if an antibiotic medication was taken at any time during the seven-day look-back period. For another resident, physician orders included Augmentin 500-125 mg every 12 hours for seven days for cellulitis, and the MAR showed the antibiotic was administered from April 3 through April 10, 2026; however, the annual MDS dated April 15, 2026 did not code Section N0415F1 for antibiotic medication use. During an interview on June 17, 2026, the Nursing Home Administrator confirmed that the MDS was coded incorrectly for both residents.
Failure to Follow Orders for Compression Therapy and Appointment Attendance
Penalty
Summary
The facility failed to follow physician's orders for a resident with cognitive impairment, daily care needs, skin tears, edema, and CAD. The resident's care plan and a wound consultant note both directed staff to apply tubi-grips to the bilateral lower extremities for edema, and a physician's order also required tubi-grips to be applied and removed each evening shift. However, observations on two separate occasions showed the resident sitting in a wheelchair with visible bandages on both lower legs and no tubi-grips applied, with the tubi-grips found on the overbed table. The resident stated that they do not put them on, and an LPN and the DON both confirmed that the tubi-grips should have been applied but were not. The facility also failed to follow a physician's order for a severely cognitively impaired, non-verbal resident with aphasia who was unable to communicate with others. The resident had an order requiring a caregiver to attend the next appointment due to the inability to communicate, but at a neurology appointment the resident did not have a caregiver present. Because no attendant was there, the physician could not assess the resident, and the DON confirmed that the resident was unable to communicate and should have had an attendant at the appointment.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled for two residents and one multi-dose vial in the medication room was left without an opening date. Resident 42 had a quarterly MDS assessment showing moderate cognitive impairment, frequent pain, routine and as-needed pain medication use, and opioid use. Physician orders included oxycodone 5 mg twice daily and oxycodone 5 mg every six hours as needed for moderate to severe pain, but the controlled drug count record showed the routine oxycodone dose was signed out of the as-needed oxycodone medication card from June 3 through June 8, 2026. The DON stated the pharmacy only sends one card of oxycodone and both routine and as-needed doses are signed out of that card despite the label instructions. Resident 63 had a comprehensive MDS assessment showing cognitive impairment, disorientation, and depression. Physician orders included lorazepam 0.5 mg daily for depression, but observation showed the lorazepam card label did not match the current order and instead read lorazepam 0.5 mg, give one tablet by mouth every eight hours as needed for agitation. In addition, observation in the TCU medication room found an opened, undated vial of Tubersol solution in the refrigerator. The facility policy required multi-dose vials to be labeled when opened, and the Tubersol manufacturer instructions stated the vial is good for 30 days once opened.
Failure to Provide Ordered Eating Assistance
Penalty
Summary
The facility failed to ensure that staff provided assistive eating devices as ordered for one resident who was moderately cognitively impaired and required staff supervision with eating. The resident’s care plan stated she was at risk for altered nutrition and was to have all foods in separate bowls for each meal. During a lunch observation, the resident was eating in bed with her food served on a regular plate rather than in separate bowls, and her meal ticket also indicated that all food items were to be in separate bowls. An LPN later confirmed that the resident did not have her food items in separate bowls and should have, according to the meal ticket.
QAPI Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior survey findings and did not ensure that plans to improve the delivery of care and services effectively addressed those repeated issues. The report states that the facility had previously developed plans of correction for deficiencies cited in the survey ending July 2, 2025, including plans that called for audits and reporting the results to the QAPI committee for review. The current survey ending June 17, 2026 identified repeated deficiencies related to quality of care, a safe environment free from accident hazards, and storage and labeling of medications. Under F684, the QAPI committee was found ineffective in maintaining compliance with the regulation regarding quality of care. Under F689, the committee failed to maintain compliance with the regulation regarding a safe environment free from accident hazards. Under F761, the committee failed to maintain compliance with the regulation regarding storage and labeling of medications.
Improper Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand-washing techniques were used during medication administration for one resident. The facility’s Medication Administration policy, dated January 7, 2026, stated that staff should follow infection control procedures, including hand sanitization for medication administration. During observation of medication administration on June 15, 2026, at 8:50 a.m., an LPN was preparing a resident’s medications and, using bare hands, took a pill out of the cup and broke it in half before administering it to the resident. The LPN later confirmed that she should not have touched the pill with her bare hands, and the DON also confirmed that the LPN should not have touched the pill with her bare hands and administered the medication to the resident.
Failure to Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that influenza and/or pneumococcal immunizations were offered and/or received for four residents reviewed. Facility policies dated January 7, 2026 stated that all residents would be offered the influenza and pneumonia vaccines. However, review of quarterly MDS assessments showed that Resident 3 did not receive the influenza vaccine during the season because it was not offered, and there was no documented evidence that it was offered or administered. Resident 13 was documented as cognitively impaired and admitted to the facility on [DATE], and the MDS indicated that she was not offered the influenza or pneumonia vaccine, with no documented evidence that either vaccine was offered. Resident 37’s quarterly MDS showed that the resident was admitted on [DATE], that the pneumococcal vaccine was not up to date, and that the resident was not offered the pneumococcal vaccine. Resident 42’s quarterly MDS showed that the resident was admitted on [DATE] and did not receive the influenza vaccine during the season because it was not offered. During interview on June 16, 2026 at 1:16 p.m., the Nursing Home Administrator stated that Residents 3, 13, 37, and 42 were not offered the influenza vaccine or the pneumonia vaccine and that they should have been.
Failure to Document COVID-19 Vaccine Offer
Penalty
Summary
The facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine for one resident. A quarterly MDS assessment for Resident 13, dated May 29, 2026, showed that the resident was cognitively impaired, had been admitted to the facility on [DATE], and was not offered the influenza or pneumonia vaccine. Review of the resident’s clinical record found no immunization or declination documentation related to the COVID-19 vaccine. During an interview on June 16, 2026, the Nursing Home Administrator stated that Resident 13 was not offered the COVID vaccination and should have been.
Failure to Provide Required QAPI Training to Nurse Aides
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not provided to five of five nurse aides reviewed: Nurse Aides 6, 7, 8, 9, and 10. Review of the nursing assistant job description showed that nurse aides were required to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulation. Personnel records showed Nurse Aide 6 was hired on February 19, 2019; Nurse Aide 7 on August 21, 2017; Nurse Aide 8 on November 23, 2012; Nurse Aide 9 on June 24, 2021; and Nurse Aide 10 on November 7, 1995. Review of each nurse aide’s continuing education transcript showed no annual education regarding QAPI training. The Nursing Home Administrator confirmed in an interview on June 16, 2026, at 2:27 p.m. that Nurse Aides 6, 7, 8, 9, and 10 did not complete the required QAPI education. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Investigate Resident Grievance Regarding Drinking Water Source
Penalty
Summary
The facility failed to thoroughly investigate and address a grievance raised by a resident and their family regarding the source of drinking water provided to the resident. The resident, who was cognitively intact and diagnosed with parkinsonism, expressed being upset when a staff member obtained drinking water from a shared bathroom sink. The resident reported this concern to staff and informed their power of attorney. Despite these reports, a review of the resident's clinical record and the facility's grievance logs showed no documentation of the complaint or any related family concerns. Interviews with nurse aides confirmed awareness of the family's preference against using bathroom water and indicated that the concern had been reported to nursing staff and management. However, staff reported that they had not received clear guidance on where to obtain water for the resident. The DON acknowledged that the concern was reported by the resident's spouse but did not consider it a grievance, citing the family's history of multiple complaints and deeming this issue a non-issue. As a result, the facility did not initiate a formal grievance investigation or resolution process as required by policy.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall and injury prevention interventions for one resident as required by its own fall management policy. The policy stated that the interdisciplinary team would review falls, discuss and care plan recommended interventions, and update the care plan and Kardex accordingly. A resident with Alzheimer's dementia, cognitive impairment, and a recent history of falls was found on two separate occasions sitting or lying on the floor after apparent falls. After the first fall, the care plan was updated to include the use of non-skid socks at bedtime as a preventive measure. Despite this intervention, the resident experienced a second fall in her room during the early morning hours. Documentation and staff interviews confirmed that the resident was not wearing non-skid socks at the time of the second fall, as required by the updated care plan. The Director of Nursing verified that the intervention was not in place when the incident occurred. This failure to ensure that the prescribed fall prevention measure was implemented resulted in a deficiency under the cited nursing services regulation.
Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete safety assessments for three residents who were provided with air mattresses. For each of these residents, clinical record reviews and observations confirmed that there was no documented evidence that an assessment for potential safety hazards related to the use of an air mattress was conducted prior to its placement on the resident's bed. This was further confirmed through interviews with the Director of Nursing, who acknowledged that safety assessments had not been completed for these residents before the air mattresses were put in use. The residents involved had significant medical conditions and care needs. One resident was cognitively impaired, required assistance with daily care, had a Stage 3 pressure ulcer, and diagnoses including dementia and Parkinson's Disease. Another resident was cognitively impaired, required extensive assistance, and had diagnoses of Parkinson's, stroke, and sarcopenia. The third resident was cognitively intact but required extensive assistance and had a history of hip fracture and contractures. Despite these vulnerabilities, the facility did not assess the safety of air mattress use for these individuals as required.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency was identified when a registered nurse left a laptop open on top of a medication cart in the hallway, displaying the Medication Administration Record (MAR) for one resident. This occurred during medication administration, when the nurse walked away from the cart to administer medications in a resident's room, leaving the confidential medical information visible to staff, residents, and visitors passing by. The facility's policy requires employees to protect resident privacy and block unnecessary access to medical records, but this was not followed in this instance. Both the nurse and the Director of Nursing confirmed that the laptop screen should not have been left open and visible in the hallway.
Failure to Verify Nursing Licenses and Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing licenses and nurse aide registry statuses were properly verified prior to employment for multiple staff members. Specifically, there was no documented evidence that the licenses of a registered nurse and a licensed practical nurse were checked with the State Board of Nursing before their respective start dates. Additionally, a nurse aide began employment without documented verification of her standing on the Pennsylvania Nurse Aide Registry until several days after her start date. The facility's policy required background checks and verification of licensure or registry status to prevent abuse, neglect, exploitation, and misappropriation. However, review of personnel files and staff interviews confirmed that these verifications were not completed as required, with reliance placed on a contracted company for background and licensure checks. The Human Resources/Payroll Director acknowledged that the necessary verifications were not documented prior to the staff members' start dates.
Failure to Follow Bowel Protocol and Physician Orders for Constipated Resident
Penalty
Summary
The facility failed to follow physician's orders and its own bowel protocol for a resident identified as being at risk for complications due to constipation. According to the facility's policy, if a resident does not have a bowel movement after three days, Milk of Magnesia (MOM) should be administered, followed by a Dulcolax suppository on day four if MOM is ineffective, and a saline enema on day five if both previous interventions fail. For the resident in question, the bowel record showed no bowel movement for six consecutive days. While MOM was administered on the third day without effect, there was no documented evidence that the Dulcolax suppository was given on the fourth day or that a saline enema was administered on the fifth day, as required by both physician's orders and facility protocol. The resident was cognitively intact, frequently incontinent of bowel and urine, and required assistance with transfers and hygiene. She reported recent constipation during an interview. The DON confirmed that the bowel protocol was not followed for this resident during the specified period. Clinical record reviews and staff interviews corroborated that the required interventions were not provided or documented as ordered.
Failure to Provide Physician-Recommended TLSO Brace
Penalty
Summary
A resident with cognitive impairment and a history of a back fracture was assessed as requiring a TLSO brace following a hospital discharge. The hospital discharge records specified the need for the brace, and this recommendation was documented in the resident's clinical records. Despite this, the facility was unable to obtain the brace from one medical supplier, and another supplier could not provide it in a timely manner. The physical therapy department was tasked with obtaining the brace, but was ultimately told not to purchase it. The resident's daughter expressed a desire for the resident to be seen by a brain and spine specialist to obtain the brace, but this did not occur. As a result, the resident never received the prescribed TLSO brace. The Director of Therapy confirmed that she could have purchased the correct brace but was instructed not to do so. The absence of the brace led to a delay in physical therapy for several months, as the resident did not have the necessary support for therapy to proceed.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to facility policy, documentation of narcotic administration must be completed in accordance with applicable law, including recording necessary information on appropriate forms. For a resident with cognitive impairment and multiple diagnoses, including Parkinson's disease, stroke, and sarcopenia, physician orders required administration of oxycodone-acetaminophen as needed for pain. The controlled drug record indicated that doses of this medication were signed out on several occasions. However, review of the Medication Administration Record (MAR) revealed no documented evidence that the medication was actually administered to the resident on the dates and times listed in the controlled drug record. The Director of Nursing confirmed that there was no documentation of medication administration on the MAR for those dates and times, despite facility policy requiring such documentation.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions prior to administering as-needed antianxiety medication. Facility policy required that person-centered, non-pharmacological approaches be used to minimize or discontinue psychotropic medication use unless contraindicated. However, for one resident with cognitive impairment, dementia, and a history of restlessness/agitation, there was no documented evidence that such interventions were attempted before administering Ativan (Lorazepam) on multiple occasions. Review of the resident’s clinical records and Medication Administration Record (MAR) showed that Ativan was given several times over a two-month period without documentation of prior non-pharmacological interventions. This was confirmed in an interview with the Director of Nursing, who acknowledged that these interventions should have been attempted before administering the medication. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication administration errors observed during 29 opportunities, resulting in a 6.90 percent error rate. Facility policy and manufacturer guidelines specify that certain medications, such as Oxycontin extended-release tablets, must not be crushed, and that oral inhalers like Dulera require the resident to rinse and spit out water after use. During medication administration, a registered nurse crushed an extended-release Oxycontin tablet before giving it to a resident, contrary to both the medication label and manufacturer instructions. The resident involved was cognitively impaired, dependent on staff for care, experiencing pain, and had multiple diagnoses including hip and humerus fractures, asthma, and respiratory failure. The same nurse also administered Dulera inhaler to the resident and provided a drink of water afterward, rather than instructing the resident to rinse and spit as required by the manufacturer. Both the nurse and the Director of Nursing confirmed these errors during interviews.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a registered nurse left a medication cart unlocked, unattended, and out of sight in the hallway while administering medications to a resident in their room. Facility policy, dated February 14, 2025, requires that medication carts remain locked when out of sight or unattended. During the observation, the nurse confirmed that the cart was not locked as required. The Director of Nursing also confirmed that the cart should have been locked when unattended. This incident was identified during a review of facility policies, direct observation, and staff interviews.
Failure to Follow Physician Notification Protocol for Change in Condition
Penalty
Summary
The facility failed to follow its established protocols for notifying a physician of a resident's change in condition. According to facility policy, if a tele-health physician does not respond within five minutes, staff are required to re-initiate the consult or contact the medical director for assistance. On the date in question, a resident with a nephrostomy tube and a history of renal insufficiency was observed to have dark red drainage from the tube, along with complaints of nausea and left flank pain. The resident's vital signs were recorded, and both the RN supervisor and charge nurse were notified. A call was placed to the tele-health physician, but no further attempts to contact a physician were documented after the initial call. The tele-health physician did not return the call until over an hour later, during which time the resident's family requested hospital transfer and called 911. Interviews with the DON and Nursing Home Administrator confirmed that staff did not follow the required steps outlined in the facility's policy when the physician did not respond promptly. This failure to adhere to protocol resulted in a delay in physician notification regarding the resident's change in condition.
Unsanitary Food Service Conditions
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by observations and staff interviews. During a review of the facility's work history report, it was noted that the vent in the kitchen was last documented as inspected on July 25, 2024. However, during observations on July 30 and July 31, 2024, a thick accumulation of dust was found on a large vent in the ceiling above two metal shelves where clean dishes and utensils were stored. This unsanitary condition was confirmed by the Director of Dining Services during an interview on July 31, 2024.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, improper development and timing of care plans, and issues with medication storage and labeling. Additionally, there were problems with food procurement, storage, preparation, and serving. These deficiencies were noted in surveys conducted on August 17, 2023, and March 27, 2024, and were found to persist in the survey ending August 1, 2024. The facility had previously developed plans of correction that involved conducting audits and reporting the results to the QAPI committee. However, the committee was ineffective in implementing these plans to ensure compliance with regulations. The repeated deficiencies indicate that the QAPI committee did not successfully address the issues related to assessment accuracy, care plan development and timing, medication management, and food service operations.
Failure to Maintain Dignity of Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of three residents who had indwelling urinary catheters by not covering their urinary drainage bags, as required by the facility's policy. The policy, dated March 1, 2024, mandates that staff refrain from practices that are demeaning to patients, such as keeping urinary catheter bags uncovered. Observations on July 29, 2024, revealed that Resident 48, who required assistance with personal hygiene and had a diagnosis of renal insufficiency, was seen with an uncovered urinary drainage bag while in his wheelchair in both his room and the therapy room. Similarly, Resident 65, who had urinary retention and required an indwelling foley catheter, was observed in the therapy room with an uncovered urinary drainage bag attached to her wheelchair. Additionally, Resident 67, who had a neurogenic bladder and required assistance for personal care, was observed lying in bed with an uncovered urinary drainage bag visible from the door. Interviews with nursing staff confirmed that the urinary drainage bags for these residents were not covered, which was against the facility's policy. The Nursing Home Administrator also confirmed that all urinary drainage bags should have privacy covers, as per the facility's policy. This failure to adhere to the policy resulted in a deficiency related to maintaining the dignity of the residents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. This deficiency was identified for two residents during a review of clinical records and staff interviews. Resident 19, who had diagnoses including Parkinson's disease, dementia, and COPD, was transferred to the emergency department after a choking incident. Despite the transfer, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Similarly, Resident 22, who had schizophrenia and was independent with personal care needs, was transferred to the hospital following hallucinations and increased aggressive behaviors. Again, there was no documented evidence of a written notice being provided to the resident's responsible party regarding the reason for the transfer. An interview with the Director of Nursing confirmed that the facility did not provide the required written notices for these hospital transfers.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical records. For one resident, there was an error in coding Section N0415I1 of the MDS, which pertains to antiplatelet medications. Despite physician's orders indicating that the resident was to receive 75 mg of Plavix daily for clot prevention, and the Medication Administration Record confirming administration during the seven-day look-back period, the MDS was not coded to reflect this. The Director of Nursing confirmed the oversight, acknowledging that the resident had indeed received the medication during the specified period. Another deficiency was identified in the discharge documentation for a second resident. The discharge MDS inaccurately coded the resident's discharge status as a transfer to a short-term general acute hospital, while nursing notes indicated that the resident was discharged home in stable condition. This discrepancy was confirmed by the Director of Nursing, who verified that the resident was discharged home and not to a hospital. These inaccuracies in the MDS assessments highlight the facility's failure to maintain accurate clinical records as required by regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for five residents, as required by their policy on person-centered care plans. The policy mandates that each resident's care plan should describe the services to be provided, any specialized services, and any services not provided due to treatment refusal. However, the facility did not adhere to this policy for several residents, leading to deficiencies in care planning. Resident 18, who had a diagnosis of Multi Drug Resistant Organism (MDRO), was observed to be on Enhanced Barrier Precautions, but there was no documented evidence of a comprehensive care plan addressing this. Similarly, Resident 21, who was in a persistent vegetative state and had a tracheostomy and feeding tube, was also on Enhanced Barrier Precautions without a corresponding care plan. Resident 23, who required continuous oxygen therapy, lacked a care plan detailing specific interventions for this need. Additionally, Resident 66, who had a PICC line and required dialysis, and Resident 68, who had a PICC line and was receiving intravenous medication, both required Enhanced Barrier Precautions. However, there was no documented evidence of comprehensive care plans for these residents. Interviews with the Director of Nursing confirmed the absence of these care plans, highlighting a systemic issue in the facility's care planning process.
Failure to Update Resident Care Plan for Foley Catheter
Penalty
Summary
The facility failed to update and revise a resident's care plan to accurately reflect the resident's specific care needs. Resident 48, who was admitted with chronic kidney disease and required assistance with personal care, had a physician's order for a foley catheter for urinary drainage dated July 13, 2024. However, the care plan dated July 9, 2024, inaccurately indicated that the resident was incontinent of urine, and an active care plan dated July 14, 2024, noted the presence of an indwelling foley catheter. Observations on July 29, 2024, confirmed the resident had a urinary drainage bag attached to his wheelchair. An interview with the Director of Nursing on August 1, 2024, revealed that the care plan was not revised to reflect the change from urinary incontinence to the use of a foley catheter, leading to the deficiency.
Failure to Complete Discharge Summary for a Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. A nursing note indicated that the resident was discharged from the facility, and verbal and written discharge instructions and medications were provided to the resident and the resident's son. However, as of three months later, there was no documented evidence of a completed discharge summary for the resident. This was confirmed through an interview with the Medical Records Coordinator.
Failure to Obtain Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for a resident who was admitted with urinary retention. The resident, who was admitted on July 22, 2024, had a foley catheter in place upon arrival at the facility. Despite the care plan indicating the need for the catheter due to urinary retention, there was no documented evidence of a physician's order for the catheter from the date of admission until July 29, 2024. Observations confirmed the presence of the catheter, and the Director of Nursing acknowledged the absence of the required physician's order during an interview.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, the performance evaluations for two nurse aides, identified as Nurse Aide 2 and Nurse Aide 5, were not conducted by their respective due dates. Nurse Aide 2's evaluation was due on January 20, 2024, and Nurse Aide 5's evaluation was due on May 13, 2024. As of July 31, 2024, there was no documented evidence that these evaluations had been completed. This deficiency was confirmed during an interview with the Nursing Home Administrator on July 31, 2024.
Failure to Label Multi-Dose Eye Drops
Penalty
Summary
The facility failed to label multi-dose containers of eye drops with the date they were opened, as observed in one of the two medication carts reviewed. Specifically, a bottle of Latanoprost Ophthalmic Solution 0.005 percent, used for reducing elevated fluid pressure in the eye, was found on Cart 2 without a date indicating when it was opened. This oversight was identified during an observation on August 1, 2024, at 3:26 p.m. The manufacturer's instructions for this medication, dated November 3, 2023, specify that once opened, the bottle may be stored at room temperature for six weeks. However, there was no evidence on the bottle to determine when it was opened or when it should be discarded. The deficiency was confirmed through interviews with the staff. A Licensed Practical Nurse responsible for Cart 2 acknowledged that the bottle was opened but not dated, which was against the facility's policy. The Director of Nursing also confirmed that the bottle should have been dated upon opening. The facility's policy, dated March 15, 2024, mandates that medications be stored properly, following the manufacturer's or provider pharmacy recommendations to maintain their integrity and ensure safe, effective drug administration. This failure to adhere to labeling protocols was a violation of the facility's medication storage policy and the nursing services regulation 28 Pa. Code 211.12(d)(1).
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents who received hospice services. The facility's policy, dated March 15, 2024, required the interdisciplinary team member to obtain the most recent hospice plan of care, hospice election form, and the physician's certification and recertification of terminal illness. However, for Resident 29, who had end-stage bladder cancer and was rarely understood, there was no documented evidence of the Hospice Certification of Terminal Illness in the clinical record as of July 31, 2024. Similarly, Resident 34, who had dementia and was understood, did not have the Hospice Benefit of Election form documented in their clinical record until it was faxed by the hospice provider. The resident started hospice care on May 30, 2024, but the required documentation was not present in the record until a later date. Interviews with the Nursing Home Administrator confirmed the absence of these critical documents in the residents' clinical records, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) for one of the residents reviewed, identified as Resident 21. The resident was cognitively impaired, required extensive assistance for daily care, and had a feeding tube and a tracheostomy. According to the facility's policy on Enhanced Barrier Precautions (EBP), staff were required to wear both gloves and gowns during high-contact care activities for residents with indwelling medical devices, regardless of their MDRO status. However, during medication administration and respiratory care, staff members did not comply with these guidelines. On two separate occasions, staff members failed to wear the required gown while providing care to Resident 21. During a medication administration, an LPN only wore gloves while accessing the resident's feeding tube, despite the signage indicating EBP measures were in place. Similarly, a respiratory therapist provided respiratory and tracheostomy care wearing only gloves. Interviews with the Infection Control Preventionist confirmed that both staff members should have worn gowns in addition to gloves while performing these tasks, as per the facility's infection control policy.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that three out of five nurse aides reviewed received the required 12 hours of in-service training annually. Specifically, Nurse Aide 1, Nurse Aide 2, and Nurse Aide 3 did not have documented evidence of completing the necessary training hours within their respective annual periods. This deficiency was confirmed through a review of the facility's list of nurse aides, their hire dates, and training hours, as well as staff interviews. An interview with the Infection Control Preventionist/Staff Educator further confirmed the lack of documentation for the required training hours for these nurse aides.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. For Resident 44, who had dementia and required assistance for care needs, a fall occurred when the resident attempted to transfer from a wheelchair to a bed without help, resulting in a head injury. The physician ordered neurological checks and monitoring of oxygen saturation levels, but the facility did not complete the neurological evaluation and failed to document oxygen saturation levels as required. For Resident 68, who was cognitively intact and receiving intravenous medication for endocarditis, the physician ordered daily weight monitoring to determine the need for furosemide administration in case of significant weight gain. However, the facility did not weigh the resident on several specified days, as documented in the Medication Administration Record. The Director of Nursing confirmed these lapses in following physician orders for both residents.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policies by not maintaining a log of all grievances received and not ensuring timely responses to grievances for two residents. Resident 4, who was alert and oriented, expressed a concern during a Resident Council Meeting about the lack of staff to assist residents into bed at night. Despite addressing this concern with the Director of Nursing, there was no documented evidence that the grievance was logged or investigated as per the facility's policy. The Director of Nursing acknowledged that an official grievance form was not completed and no further investigation was conducted at that time. Additionally, Resident 7 filed a grievance regarding long call bell response times and not receiving pain medications. The facility failed to document a thorough investigation of this grievance, including interviews with staff on duty during the incident and verification of the resident's medication administration. There was no summary of findings or conclusions regarding the resident's concerns, nor any documented corrective actions taken by the facility. The Nursing Home Administrator confirmed the lack of documentation and investigation into Resident 7's grievance.
Failure to Update Resident Care Plan for Mobility Status
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect their current care needs, as required by their policy. The policy mandates that care plans be customized to each resident's preferences and needs, and reviewed and revised by the interdisciplinary team after each assessment. In this case, the care plan for a resident with a history of seizures and traumatic brain injury was not updated to reflect their improved mobility status. The resident's care plan, dated March 4, 2024, indicated that they had an activities of daily living self-care deficit and required a mechanical lift for transfers, despite a nursing note from December 8, 2023, indicating that the resident was ambulating independently. Observations on March 27, 2024, confirmed that the resident was transferring and ambulating independently throughout the facility. However, there was no documented evidence that the care plan had been updated to remove the requirement for a mechanical lift. An interview with the Director of Nursing on the same day confirmed that the care plan should have been updated to reflect the resident's current ability to transfer independently without the use of a mechanical lift.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pennknoll Village | 3 mi | ★★★★★ | 16 | 0 |
| Homewood Living Martinsburg, Inc | 21.9 mi | ★★★★★ | 4 | 0 |
| Morrisons Cove Home | 21.9 mi | ★★★★★ | 8 | 0 |
| Windber Woods Senior Living & Rehabilitation Ctr | 24.6 mi | ★★★★★ | 16 | 0 |
| Meadow View Nursing Center | 24.7 mi | ★★★★★ | 12 | 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 August 2026) and official state health department websites.