Bedford Co Nursing Home

In the surveyor’s words

From the most serious findings on record at Bedford Co Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF658Feb 16, 2023

  Based on observations, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice during medication administration for one of five residents in the survey sample (Resident #1), resulting in an opioid overdose, which required hospitalization . The findings include: Registered nurse (RN) #1 failed to compare the morphine on-hand to Resident #1's physician's order prior to giving the medication, resulting in the administration of a 100 mg (milligram) dose, rather than the 10 mg dose ordered by the physician. Recognition that a higher concentration of liquid morphine was selected than that listed on the physician's order was not made until after administration of the medication. […]

• Actual harm, isolatedF760Feb 16, 2023

  Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of five residents (Resident #1) was free from a significant medication error, which resulted in an opioid overdose requiring hospitalization . The findings include: Resident #1 was administered a 100 mg (milligram) dose of oral morphine solution, ten times the physician's order that required a 10 mg dose. The medication error resulted in an emergency transfer and hospitalization of Resident #1 for treatment of the overdose. Registered nurse (RN) #1 failed to compare the morphine on-hand to Resident #1's physician's order prior to giving the medication resulting in the administration of a 100 mg (milligram) dose rather than the 10 mg dose ordered by the physician. […]

• No harm, potential for more than minimal, patternF849Aug 5, 2021

  Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure professional standards of practice by a hospice provider for one of 19 residents in the survey sample, Resident #14. Records of weekly hospice visits for Resident #14, including nursing assessments and direct-care services were not provided to the facility as required in the hospice services agreement. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #14 with short and long-term memory problems and severely impaired cognitive skills. Resident #14's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF842Apr 15, 2025

  Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for the one resident in the survey sample (Resident #1). The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, ischemic heart disease, chronic kidney disease, peripheral artery disease, dementia, hypertension, anxiety, history of myocardial infarction and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills. R1's closed clinical record documented a physician's order dated [DATE] changing the resident's resuscitation status from full code (requiring cardiopulmonary resuscitation) to do not resuscitate (DNR). […]

• No harm, potential for more than minimal, isolatedF658Aug 16, 2023

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice during a medication pass on one of three units (100 unit). The findings include: A nurse documented that the medication Eliquis was administered to Resident #61 (R61) during an 8:00 a.m. medication pass when the medicine was omitted. The Eliquis was not administered to Resident #61 until 8/15/23 at 9:20 a.m. A medication pass observation was conducted 8/15/23 at 7:57 a.m., with licensed practical nurse (LPN #2) administering medications to R61. The medication Eliquis was omitted and not administered to R61 during the 8:00 a.m. […]