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 Wellness & Rehabilitation during CMS and state inspections, most recent first.
Failure to Update Care Plans for EBP: The facility failed to include EBP in the care plans for 5 residents with conditions such as dialysis access, PEG/G-tube, wounds, MRSA, and a urostomy. Records showed some residents were on the EBP list or had EBP orders, but the care plans did not reflect the precautions. Staff interviews confirmed that gowns and gloves were used based on doorway signage, while the MDS nurse stated EBP information should be in the care plan.
Improper Food Storage and Cross-Contamination in Kitchen: Surveyors observed multiple food items in the kitchen that were unsealed, undated, or improperly labeled in the walk-in freezer and walk-in refrigerator, along with dented canned goods in dry storage. A Dietary Aide was also observed touching food products with used gloves that had been used for raw chicken, and she stated she should have removed the gloves and washed her hands to avoid contaminating other items. The Dietary Supervisor acknowledged the importance of sealing opened food, sealing frozen food, and avoiding dented cans due to contamination concerns.
Inaccurate Diabetes Diagnosis on MDS: A resident admitted with dementia was incorrectly assigned a Type 1 DM diagnosis in the chart and on a quarterly MDS, while the annual MDS omitted DM. Record review showed no BG readings, no active DM orders, and no care plan for DM. An LVN stated the diagnosis source could not be found and it was an error; staff also noted the importance of accurate diagnoses for MDS accuracy and facility payment.
Failure to Obtain and Document a Resident’s Weight: A resident admitted with DM, muscle wasting, and atrial fibrillation was supposed to have admission and follow-up weights obtained because of malnutrition risk. The resident stated she had never been weighed at the facility, while the EHR initially showed a 0.0-pound weight and staff later said it was incorrect and may have been entered on the wrong chart. Interviews showed confusion among restorative aides, the DON, ADONs, DOR, and ADM about who was responsible for weighing residents and entering the data, and the shared spreadsheet used for weights could be altered without tracking edits.
A resident with hemiplegia, dementia, and pain had a family meeting with the DON and SW about medication changes, including gabapentin, Tylenol, and tramadol. The facility could not produce the original handwritten note from the meeting, and the SW’s screenshot showed a discrepancy between a partial note and a fuller note that included “DC: gabapentin.” Staff gave differing accounts of what was discussed, while the ADM refused to provide the full note when requested.
A resident who was always incontinent of urine and bowel did not receive appropriate perineal care during an incontinence episode. Two CNAs failed to clean the resident's penile shaft and did not pull back the foreskin to clean the meatus area, as required by facility policy. The resident expressed concern that not all of the bowel movement was removed, and interviews with staff confirmed that proper care steps were missed.
Staff failed to perform proper hand hygiene and glove changes during incontinence care for two residents with complex medical conditions. In both cases, CNAs did not sanitize their hands before donning gloves, between glove changes, or before leaving the room, and used soiled gloves to handle clean items and reposition residents. These actions were contrary to facility policy and were acknowledged by the staff involved during interviews.
A bed bound resident with a history of falls, metabolic encephalopathy, glaucoma, and heart failure was found unable to access her call light, which was placed under a side rail and out of reach. The resident was observed calling out for help, and staff confirmed the call button should have been accessible, as required by facility policy and the resident's care plan.
A social worker without state-approved feeding assistant training assisted a resident with moderate cognitive impairment and neurological conditions during a meal. The staff member was observed feeding the resident, despite not having completed the required training, and the facility lacked a policy or training for non-nursing staff on assisted feeding.
A facility failed to create a baseline care plan within 48 hours for a resident with acute kidney failure and an indwelling Foley catheter. The absence of a care plan meant there were no documented interventions for the resident's conditions, as observed during a record review and an incident involving a cloudy catheter collection bag. The DON confirmed that the interdisciplinary team did not complete the plan within the required timeframe, contrary to the facility's Care Planning policy.
A facility failed to include enteral feeding in a resident's comprehensive care plan. The resident, with conditions such as hemiplegia and diabetes, had orders for enteral feeding, but the care plan lacked specific goals and interventions. The DON acknowledged the omission, which contradicted the facility's policy requiring comprehensive care plans to describe necessary services for residents' well-being.
A resident on Enhanced Barrier Precaution did not receive proper infection control measures during catheter care. RN A and ADON B failed to wear gowns and did not perform aseptic technique, as required by the facility's policies. The oversight was confirmed through staff interviews, highlighting a lapse in adherence to infection prevention protocols.
A medication cart was left unlocked and unattended with keys on top, due to an LVN being distracted by assisting a CNA. This breach in protocol was against the facility's policy, which requires medication carts to be locked and keys secured by authorized personnel.
Two residents experienced neglect due to inadequate transportation services, resulting in one resident waiting over four hours after a medical appointment, missing a meal and pain medication, and another resident missing and being late to appointments due to van issues and scheduling delays. These incidents were linked to the facility's insufficient transportation resources and lack of effective communication and tracking systems.
A resident with severe cognitive impairment and multiple medical conditions was found with a foley catheter bag lying on the floor, contrary to the care plan and infection control policies. The LVN corrected the issue upon observation, and both the DON and CNA acknowledged the infection risk. The facility's policy emphasized keeping collection bags off the floor to prevent infections.
Failure to Update Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 5 of 5 residents reviewed, and failed to update each resident’s care plan to reflect the need for Enhanced Barrier Precautions (EBP). Record review showed Resident #1 had diagnoses including dependence on renal dialysis and had an order for EBP related to a dialysis fistula, but the care plan had no active notation of EBP. Resident #2 had cognitive communication deficit and was listed on the EBP list for PEG placement, but the care plan had no active notation of EBP. Resident #3 had diagnoses including MRSA, a cardiac pacemaker, and quadriplegia C5-C7 complete, had an order for EBP related to a urostomy and wounds, but the care plan had no active notation of EBP and the EBP list did not include the resident. Resident #4 had diagnoses including gastrostomy status and Rett syndrome, was listed on the EBP list for PEG placement, but had no active EBP order and no active notation of EBP in the care plan. Resident #5 had diagnoses including a cutaneous abscess of the left lower limb, abscess of tendon sheath of the left thigh, and surgical aftercare, had an order for EBP related to a wound, but the care plan had no active notation of EBP. The facility’s EBP list reflected that Residents #1, #2, #4, and #5 were on EBP, while Resident #3 was not listed despite the order for EBP. During interviews, CNA B stated he wore a gown and gloves for residents on EBP and followed the sign outside the resident’s door. LVN A stated nursing staff were responsible for wearing gowns and gloves for residents with wounds, indwelling catheters, dialysis sites, and G-tubes, and that signage outside the room helped staff remember what to wear. The IP stated residents with indwelling medical devices and wounds were on EBP and that the EBP postings were on the doorway, but did not know who was responsible for putting the EBP information in the care plan. The MDS Nurse stated EBP information should be in the care plan and that the Treatment nurse, DON, and nurse management were responsible for updates. The Administrator stated nurse management was responsible for care plan updates and said he would do an in-service. The facility policy stated each resident’s comprehensive care plan would be developed based on individual assessed needs and describe services to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Improper Food Storage and Cross-Contamination in Kitchen
Penalty
Summary
The facility failed to store, prepare, and handle food in accordance with professional food safety standards in its only kitchen. During an initial tour of the kitchen on 12/09/2025, surveyors observed multiple food items in the walk-in freezer that were not properly sealed, labeled, or dated, including a clear bag of hot dogs with an illegible date, an unsealed bag of beef patties in an open box dated 12/8/2025 and labeled open, an unsealed bag of chicken legs in an open box dated 11/20/2025, and an open and unsealed box of cinnamon roll dough. In dry storage, surveyors also observed canned goods with dents, including grape jelly dated 10-27-25, tomato sauce dated 9-30-25, and Champinones mushrooms dated 11-25-25. In the walk-in refrigerator, surveyors observed an unsealed tub of sour cream labeled opened 10/28/25 with a use-by date of 11/29/25, and a large bag of pepper jack cheese cubes that was undated and had a manufacturer best-by date of 11/25/2025. Surveyors also observed a Dietary Aide touching various products in the walk-in cooler while wearing used food grade gloves that appeared to have seasonings on them. During interview, the Dietary Aide stated the gloves she was wearing in the walk-in refrigerator were the same gloves used to prepare raw chicken, and that she was supposed to remove them and wash her hands because she did not want to contaminate anything else. During interview, the Dietary Supervisor stated it was important for food items in bags to be sealed after opening because of contamination from other objects, that frozen food items needed to be sealed because they can be freezer burnt, and that dented canned goods could create a broken seal and cause contamination and botulism. The facility's Dietary Department policy required sanitation and safety standards, and the FDA Food Code excerpts in the record addressed safe food, glove use limitation, and date marking for ready-to-eat food held after opening.
Inaccurate Diabetes Diagnosis on MDS
Penalty
Summary
Resident #72 was admitted with a primary diagnosis of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. On 10/1/2024, the resident was diagnosed with Type 1 Diabetes Mellitus. However, record review showed the resident’s quarterly MDS listed an active diagnosis of Diabetes Mellitus, while the annual MDS did not include Diabetes Mellitus among the active diagnoses. The resident’s blood sugar graph from 12/1/2023 through 12/10/2025 did not show any blood glucose readings, the order summary dated 12/11/2025 did not show active orders for Diabetes Mellitus, and the care plan dated 12/11/2025 did not include a plan of care for Type 1 Diabetes Mellitus. During interview, LVN G stated the only way the resident could have received the Type 1 Diabetes Mellitus diagnosis was through a doctor’s order for a new diagnosis or a hospital diagnosis, but after reviewing the record he could not find anything showing where the diagnosis came from and said it was an error. He stated he obtained an order to discontinue the diagnosis and said two MDSs had to be modified. LVN I and RN J stated correct diagnoses were important for accurate MDSs and facility payment, and RN J stated she did not think there was a risk because nothing was being done for the diagnosis. The facility’s RAI Process policy stated that all information recorded within the MDS must reflect the resident’s status at the ARD.
Failure to Obtain and Document Resident Weight
Penalty
Summary
The facility failed to ensure that a resident at risk for malnutrition had weights obtained and documented according to admission requirements and physician orders. The resident was admitted with diagnoses including diabetes mellitus, muscle wasting, and atrial fibrillation, and the admission MDS reflected a weight of 0 pounds. The resident’s care plan noted monitoring for loss of appetite, and physician orders directed that the resident be weighed weekly for 4 weeks and monthly thereafter because of risk for malnutrition related to longstanding persistent atrial fibrillation. Record review showed the resident’s electronic weight record contained a weight of 0.0 pounds completed on 12/03/25, and no other weights were present at that time. The resident stated during interview that she had never been weighed at the facility and reported prior weights of about 182 pounds at baseline and 192 pounds at the hospital. Skilled evaluations also reflected the resident’s weight as 0.0 pounds. Later, ADON A stated she struck out the 0.0-pound entry in the electronic record because it was obviously not correct and believed the weight had been entered on the wrong resident’s chart. Staff interviews showed confusion about responsibility for obtaining, documenting, and entering weights. ADON A, RN C, ADON B, the DOR, and the ADM each described restorative aides as taking weights and the DON as documenting them in the electronic health record, while also noting the DON had quit the prior week and responsibilities were shifting. The DOR stated the shared spreadsheet used for weights could be altered by anyone with access and had no time stamps or edit tracking. A restorative aide stated she had weighed the resident using a mechanical lift and sling and gave the weight to the DOR, but the exact date could not be verified from the spreadsheet. The facility policy stated weights are obtained upon admission and/or readmission, then weekly for 4 weeks and monthly thereafter.
Incomplete and Inaccurate Documentation of Resident Pain Medication Meeting
Penalty
Summary
The facility failed to provide complete, accurately documented, and readily accessible information for one resident when it did not produce the original handwritten notes from a meeting involving the resident, the resident’s family, the DON, and the SW. The deficiency centered on whether the notes reflected a medication discussion that included discontinuing gabapentin and using Tylenol or tramadol as needed, along with other pain-related adjustments. The report states that the facility could not provide the original note during the survey, and the ADM refused to give the full handwritten note when requested. Resident #7 was an older woman admitted with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, along with dementia and anxiety. Her MDS reflected a BIMS of 13. The record showed a progress note stating the resident’s family requested that tramadol be reduced to bedtime only and gabapentin be discontinued because it was ineffective. The order summary later showed gabapentin at bedtime and tramadol as needed for pain, and it did not show an active Tylenol order. During interviews, the resident’s RP, RN H, LVN I, the ADM, the SW, Med Aide K, and RN C gave differing accounts of what was discussed and documented. The SW showed a handwritten note on her phone that initially appeared partial, then a fuller screenshot that included “DC: gabapentin” above “use tramadol or tylenol PRN.” The SW later said she deleted the note and was unsure why there was a discrepancy. The ADM stated the note forwarded to him was the original note, but he would not verbally identify the discrepancy when asked. The facility policy required nursing documentation to be concise, clear, pertinent, accurate, evidence based, dated, timed, signed, and to include communications with family, DPOA, or physician in nurse’s notes.
Failure to Provide Proper Perineal Care for Incontinent Male Resident
Penalty
Summary
A deficiency occurred when a male resident who was always incontinent of urine and bowel did not receive appropriate perineal care during an incontinence episode. The resident, who was dependent on staff for toileting hygiene and had diagnoses including diabetes, hemiplegia, and viral hepatitis, was observed after waiting several hours for incontinence care. Upon care, two CNAs entered the room and began cleaning the resident, who had a large amount of bowel movement present. During the process, CNA B failed to clean the resident's penile shaft and did not pull back the foreskin to clean the meatus area, as required for uncircumcised males. Additionally, CNA B changed gloves without performing hand hygiene. The resident expressed concern that not all of the bowel movement was removed from his groin area, prompting further cleaning, but the required steps for proper perineal care were still not completed. Interviews with the involved CNAs confirmed that proper perineal care steps were missed, specifically the cleaning of the penis and foreskin. The facility's policy required staff to wash the penis from the ureteral opening, pull back the foreskin on uncircumcised males, and clean under it, which was not followed in this instance. The DON also confirmed that these steps were mandatory and that failure to perform them could lead to infection. The deficiency was identified through observation, interview, and record review, and was limited to one resident reviewed for catheter and incontinence care.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing proper hand hygiene during incontinence care for two residents. For the first resident, a male with diagnoses including diabetes, hemiplegia, and viral hepatitis, two CNAs entered the room to provide care. Both CNAs donned gloves and gowns, but neither performed hand hygiene before putting on gloves. During the care process, gloves were changed without hand hygiene, and one CNA left the room with trash without sanitizing her hands. The resident expressed concern that not all soiling was removed from his groin area, and both CNAs later acknowledged missing required hand hygiene steps during the procedure. For the second resident, a female with seizures, hemiplegia, and mild cognitive impairment, two CNAs sanitized their hands before entering the room and donned gloves and gowns. However, during perineal care, one CNA used the same gloves to clean the resident and then to place a clean brief and reposition her, without changing gloves or performing hand hygiene between these steps. Both CNAs only removed their gloves and washed their hands after completing all care and repositioning tasks, contrary to facility policy. Interviews with the involved CNAs confirmed their awareness of the required hand hygiene protocols, including performing hand hygiene before care, after glove changes, and before leaving the resident's room. Facility policies reviewed emphasized the importance of hand hygiene as the primary means to prevent infection, specifying that glove use does not replace hand hygiene and that hand hygiene must be performed at key points during resident care. Despite this, the observed failures in hand hygiene and glove changes during incontinence care led to the cited deficiency.
Call Light System Inaccessible for Bed Bound Resident
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be inaccessible, as the call button was located under the right positioning side rail and out of the resident's reach. The resident, who was bed bound and dependent on staff for assistance, was observed yelling and calling out for help because she could not access the call button. Staff interviews confirmed that the call button should have been within the resident's reach, and facility policy requires call cords to be placed within reach to enable residents to alert nursing staff from their rooms. The resident involved had a history of metabolic encephalopathy, glaucoma, heart failure, and was at risk for falls due to poor balance and unsteady gait. Her care plan specifically included the intervention to ensure the call light was within reach and to encourage its use for assistance. Despite these documented needs and interventions, the call system was not accessible at the time of the surveyor's observation, resulting in the resident being unable to summon help except by yelling.
Untrained Staff Assisted with Resident Feeding
Penalty
Summary
A deficiency occurred when a social worker, who had not completed a state-approved feeding assistant training course, assisted a resident with eating. The resident, an elderly female with Parkinson's Disease, generalized anxiety disorder, and essential tremor, was admitted with moderate cognitive impairment and required supervision with eating. During observation, the social worker was seen feeding the resident a tuna sandwich by bringing the food to her mouth, while the resident was unable to feed herself independently due to her condition. Interviews with the social worker, administrator, and DON revealed that the social worker was not trained in feeding assistance and that the facility did not provide specific training on feeding residents to non-nursing staff. The social worker's training record confirmed the absence of a state-approved feeding training course. The administrator and DON stated that only CNAs and nurses received feeding training as part of their competencies, and there was no policy on assisted feeding for other staff.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which included necessary instructions for effective and person-centered care. This deficiency was identified for a resident who was admitted with acute kidney failure and depression, and who required specific care for an indwelling Foley catheter. The absence of a baseline care plan meant that there were no documented interventions or plans for the resident's acute kidney failure or catheter care, as observed during a record review and an incident where a nurse had to change a cloudy catheter collection bag. Interviews with the Director of Nursing (DON) revealed that the interdisciplinary team, including the Assistant Director of Nursing (ADON), dietitian, administration, social worker, activity director, and therapy manager, were responsible for developing the baseline care plan. However, this plan was not completed within the required timeframe, as confirmed by the DON. The facility's Care Planning policy mandates that a person-centered baseline care plan be developed within 48 hours of admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The failure to adhere to this policy could lead to ineffective care and unmet resident needs, as noted by the DON.
Failure to Include Enteral Feeding in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required enteral feeding. The resident, a male with a history of hemiplegia, hemiparesis, type 2 diabetes, and acute kidney failure, was admitted to the facility and had orders for enteral feeding, including bolus feeding five times a day, flushing, and cleansing of the g-tube every shift, as well as an NPO order. Despite these orders, the resident's comprehensive care plan did not include specific goals and interventions related to the enteral feeding. The Director of Nursing (DON) acknowledged in an interview that the enteral feeding should have been included in the comprehensive care plan, as it is essential for ensuring that all staff can provide proper care by referencing the care plan. The facility's policy requires that each resident's comprehensive care plan describe the services needed to maintain the resident's highest practicable well-being and be completed within seven days after the comprehensive admission assessment. However, the care plan for this resident did not meet these requirements, leading to a deficiency in care planning.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for a resident on Enhanced Barrier Precaution (EBP). During an observation, RN A and ADON B did not wear the required Personal Protective Equipment (PPE) while providing catheter care to a resident. Despite a sign indicating EBP at the resident's door, RN A only wore gloves and did not use a gown. Additionally, RN A did not perform aseptic technique when changing the catheter bag, as he failed to disinfect the catheter port and the new inlet tube with an alcohol wipe before connecting them. Interviews with the staff confirmed the oversight, with both RN A and ADON B acknowledging their failure to wear gowns and perform aseptic technique. The Director of Nursing expressed surprise at the lapse, noting that both staff members had been trained in infection control. The facility's catheter care manual and Standard and Enhanced Precaution Policy clearly outlined the need for aseptic technique and PPE use during high-contact resident care activities, which were not adhered to in this instance.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. During an observation, a medication cart was found unlocked with the keys lying on top, unattended by any facility staff. LVN N, who was responsible for the cart, was distracted by assisting a CNA with a blood sugar patient and forgot to lock the cart and take the keys with her. This oversight left the cart vulnerable to unauthorized access. Interviews with LVN N, the DON, and the ADM confirmed the expectation that medication carts should be locked and keys kept secure at all times. The facility's policy on medication storage, dated September 2018, mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. The failure to adhere to these protocols could lead to unauthorized access to medications, posing risks to residents and staff.
Neglect Due to Inadequate Transportation Services
Penalty
Summary
The facility failed to ensure residents were free from neglect, specifically in the case of two residents who experienced significant delays in transportation for medical appointments. One resident, who was wheelchair-bound and had a history of PTSD, was left waiting for over four hours after completing a medical appointment. This delay caused the resident to miss a meal and a scheduled dose of pain medication, leading to psychosocial harm as the resident felt abandoned and experienced increased pain due to prolonged sitting. Another resident faced transportation issues on two consecutive days. On the first day, the resident missed a medical appointment due to a malfunctioning van lift, and on the second day, the resident was an hour late for an appointment. These delays were attributed to the facility's inadequate transportation resources, including only one van and two drivers, which were insufficient to meet the needs of all residents requiring transportation. Interviews with facility staff revealed systemic issues contributing to these deficiencies, such as a lack of communication tools for drivers, insufficient transportation resources, and a lack of a transportation log to track residents' appointments and pick-up times. The facility's transportation manager and drivers highlighted these challenges, noting that the facility's budget cuts had exacerbated the problem by limiting the use of outsourced transportation services.
Infection Control Deficiency Due to Improper Foley Bag Handling
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper handling of a foley catheter bag for a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including West Nile Virus with Encephalitis, Enteropathogenic Escherichia Coli Infection, and Myocardial Infarction, was observed with his foley bag lying on the floor. This was contrary to the care plan which specified that the drainage bag should be kept off the floor to prevent infection. The resident was unable to manage his toileting hygiene independently, requiring full assistance from staff. During observations and interviews, it was noted that the foley bag had been on the floor for at least 45 minutes, as confirmed by a family member. The Licensed Vocational Nurse (LVN) acknowledged the issue and took steps to correct it by wearing protective gloves and reattaching the bag. The Director of Nursing (DON) and a Certified Nursing Assistant (CNA) both recognized the infection control risk posed by the bag being on the floor, emphasizing the responsibility of nursing staff to ensure proper catheter care. The facility's Catheter Care Policy also highlighted the importance of keeping collection bags off the floor to maintain unobstructed urine flow and prevent infections.
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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) |
|---|---|---|---|---|
| La Dora Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Parkwood Village | 1.1 mi | ★★★★★ | 1 | 0 |
| Westpark Rehabilitation And Living | 1.5 mi | ★★★★★ | 27 | 0 |
| Hurst Plaza Nursing & Rehab | 1.6 mi | ★★★★★ | 6 | 0 |
| Forum Parkway Health & Rehabilitation | 1.7 mi | ★★★★★ | 4 | 0 |
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