Bedford Post Acute

In the surveyor’s words

From the most serious findings on record at Bedford Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF583Apr 22, 2021

  Based on review of facility policies, information provided to staff upon hire, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of nine residents reviewed (Resident 5), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: The facility's abuse policy, dated February 10, 2021, included that staff were not to mentally abuse residents, which included humiliation, threats of punishment, or deprivation. […]

• Immediate jeopardy, isolatedF600Apr 22, 2021

  Based on review of facility policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from mental abuse for one of nine residents reviewed (Resident 5), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: The facility's abuse policy, dated February 10, 2021, included that staff were not to mentally abuse residents, which included humiliation, threats of punishment, or deprivation. […]

• No harm, potential for more than minimal, patternF628Jun 17, 2026

  Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman (an independent, impartial official appointed to investigate and help resolve complaints) of a transfer to the hospital for five of 35 residents reviewed (Residents 1, 6, 9, 65 and 75). Findings include: A facility policy regarding transfer or discharge notices, dated January 7, 2026, indicated that residents (or resident representatives) are notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the office of the State Long-Term Care Ombudsman. […]

• No harm, potential for more than minimal, patternF689Jun 17, 2026

  Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible for two of 35 residents reviewed (Residents 2, 37) and failed to ensure that each resident received assistance devices to prevent accidents for two of 35 residents reviewed (Residents 15, 53).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2026, indicated that the resident was mildly cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia and epilepsy (brain condition that causes repeated seizures).Observation… […]

• No harm, potential for more than minimal, patternF689Jul 2, 2025

  Based on review of clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to complete safety assessments for three of 25 residents reviewed (Residents 9, 17, 36) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated May 30, 2025, revealed that the resident was cognitively impaired, required assistance with daily care needs, had a Stage 3 pressure ulcer (pressure wound that forms as a result of prolonged pressure involving the fat layers beneath the skin), and had diagnoses that included dementia and Parkinson's Disease (a degenerative brain condition that affects muscle control and movement). […]