Deficiency Records for Bedford Skilled Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Bedford Skilled Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-17 | 2023-09-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-17 | 2023-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-17 | 2023-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-17 | 2023-09-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-09-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-17 | 2023-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-09-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-17 | 2023-09-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-17 | 2023-09-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | 2023-09-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-17 | 2023-09-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-17 | 2023-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-17 | 2023-09-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-17 | 2023-09-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-17 | 2023-09-27 | N |
| Meet other general requirements. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-17 | 2023-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-10 | 2023-06-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-06-20 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-08 | 2022-10-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-04 | 2022-09-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-04 | 2022-09-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-08-04 | 2022-09-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-04 | 2022-09-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-04 | 2022-09-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-09-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-09-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-04 | 2022-09-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-04 | 2022-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-09-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-09-06 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Meet other general requirements. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-08 | 2022-09-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-30 | 2022-08-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-08-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-17 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Meet other general requirements. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-10-18 | 2021-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-09 | 2021-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-11-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-09 | 2021-11-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-09 | 2021-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-09 | 2021-11-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-22 | 2021-05-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-22 | 2021-05-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-22 | 2021-05-11 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-22 | 2021-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-22 | 2021-05-11 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-22 | 2021-05-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-22 | 2021-05-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-12 | 2021-05-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-12 | 2021-05-11 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-04-12 | 2021-05-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-31 | 2021-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-31 | 2021-05-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-31 | 2021-05-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-24 | Not Fixed | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-06 | Not Fixed | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-06 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-06 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | Not Fixed | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-07-06 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-06 | Not Fixed | Y |
