Bickford Health Care Center

In the surveyor’s words

From the most serious findings on record at Bickford Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 13, 2026

  Based on observation, record review, and staff interviews, the facility failed to ensure the resident was free from neglect when the facility failed to notify the local police department within 15-minutes when a resident was identified missing from the facility in accordance with facility policy, and failed to notify emergency services timely when a resident was found unresponsive outside the building in below freezing temperatures. The failures resulted in a finding of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Feb 13, 2026

  Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1), the facility failed to adequately supervise a resident with a diagnosis of dementia and was identified wander risk who ambulated independently. Resident #1 was able to exit the facility without staff knowledge in subfreezing temperatures. The failure resulted in a finding of Immediate Jeopardy. The findings include:Resident #1's diagnoses included dementia.Record review identified Resident #1's code status was Do Not Resuscitate (DNR).The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors,… […]

• Actual harm, isolatedF686Jan 13, 2026

  Based on observation, clinical record review, facility policy review and interviews, the facility failed to ensure residents at high risk for pressure ulcer development were promptly assessed and provided timely preventative interventions. Specifically, for one sampled resident (Resident #7), the facility failed to implement turning and repositioning, and other preventive measures despite known risk factors and an existing pressure injury and failed to develop and implement a care plan to prevent pressure ulcers. These failures resulted in the development of a new pressure injury to the coccyx that progressed to an unstageable wound and ultimately to a Stage 4 pressure ulcer, causing actual harm. […]

• Actual harm, isolatedF686Mar 14, 2025

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to report a deterioration in wound status to the physician, ensure wound care was completed in accordance with physicians orders, and ensure an air mattress was provided timely which resulted in a deterioration of a pressure ulcer. The findings include: Please cross reference F 580 and F 658. Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), dementia with behavioral disturbances, type 2 diabetes mellitus and muscle weakness. […]

• Actual harm, isolatedF689Dec 11, 2024

  Based on clinical record review, facility documentation and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to complete monthly maintenance checks to ensure resident's bedframes were free from sharp/jagged edges in accordance with manufacturer's recommendations resulting in a laceration to the leg requiring (8) eight sutures. The findings included: Resident #2 had diagnoses which included Parkinsonism, major depressive disorder, epilepsy and epileptic syndromes. […]