Bedford Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bedford Center for Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF550Mar 19, 2025

  Based on observation, record review, and interviews conducted during the Recertification Survey from 03/12/2025 to 03/19/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #40) of 1 resident reviewed for Dignity out of 39 total sampled residents. Specifically, the Licensed Practical Nurse administered insulin to Resident #40 while they were seated in the hallway without providing any form of privacy. The findings are: The facility's policy titled Quality of Life- Dignity, implemented 07/2017 and last reviewed 01/12/24, stated that staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. […]

• No harm, potential for more than minimal, isolatedF684Mar 19, 2025

  Based on observations, staff interviews and record review conducted during the Recertification Survey from 03/12/2025 to 03/19/2025, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 (Resident #40) of 6 residents observed for Medication Administration task. Specifically, Resident #40, admitted with a diagnosis of Diabetes Mellitus, was administered Lantus Insulin by the Licensed Practical Nurse, without confirmation of the blood sugar results received from the Freestyle Libre (a blood sugar monitoring device attached to the skin). Further, there was no documentation of a Physician's Order for the Freestyle Libre device for blood sugar monitoring. […]

• No harm, potential for more than minimal, isolatedF761Mar 19, 2025

  Based on observations, interviews, and record review conducted during the Recertification and survey from 03/12/2025 to 03/19/2025, the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (Unit 2) of 5 medication storage areas reviewed. Specifically, controlled medications were not properly stored in a double cabinet in the Unit 2 medication room. This was observed during the Medication Storage task. The findings are: The facility policy titled Controlled substances revised 12/15/2024 stated the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. […]

• No harm, potential for more than minimal, isolatedF610Jun 13, 2023

  Based on observation, interview and record review conducted during an abbreviated survey (NY00294793), the facility did not ensure that an elopement incident was thoroughly investigated. This was evident in 1 out of 4 residents sampled for wandering and elopement (Resident #1). Specifically, Resident #1 eloped from the facility on 04/22/2022. The facility investigation documented that they reviewed the outdoor security camera footage and it indicated that Resident #1 walked out of the building at 7:39 am. The facility investigation did not determine how Resident #1 exited the unit. The findings are: The undated Policy and Procedure on Elopement documented that staff shall investigate all cases of missing residents. […]

• No harm, potential for more than minimal, isolatedF689Jun 13, 2023

  Based on interviews and record review conducted during an abbreviated survey (NY00294793), the facility did not ensure each resident received adequate supervision to prevent elopement. This was evident in 1 out of 4 residents sampled for wandering and elopement (Resident #1). Specifically, Resident #1 who had a history of attempted elopement, was identified at high risk for elopement and was assigned a wander alert device (a device that alerts staff when the resident is exiting the building), exited the facility without staff knowledge on 04/22/2022 at 7:39am. […]