Majestic Care of Bedford

In the surveyor’s words

From the most serious findings on record at Majestic Care of Bedford, in the surveyor’s own words.

• Actual harm, isolatedF689May 3, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent repeated falls for a resident assessed to be a high risk for falls and who wandered resulting in two unwitnessed falls with injury that required acute care medical intervention for 1 of 6 residents reviewed for accidents (Resident 57), the facility failed to ensure implementation of a fall care plan intervention for 1 of 6 residents reviewed for accidents (Resident 20), and the facility failed to ensure full sharps containers kept in a soiled utility room were inaccessible, an unlocked and unattended lab cart containing syringe needles was inaccessible, an unlocked and unattended treatment cart containing syringe needles was inaccessible, and toilet bowel cleaner and surface cleaner… […]

• Actual harm, isolatedF725May 3, 2021

  Based on observation, interview, and record review, the facility failed to provide sufficient staffing in order to provide adequate supervision to prevent repeated falls which resulted in major injury for 1 of 6 residents reviewed for accidents. (Resident 57) Findings include: On 4/28/2021 from 1:57 p.m. to 2:10 p.m., Resident 57 was observed to be walking around Unit 1 with a Merry Walker (an adaptation used to allow for freedom of movement without being restricted to walking with someone assisting them). Staff were observed not to be near the resident nor supervising. On 4/29/2021 from 11:03 a.m. to 11:20 a.m., Resident 57 was observed to be walking around Unit 1 and was unsteady on her feet. Staff were observed not to be near the resident nor supervising. […]

• Actual harm, isolatedF600Feb 23, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse from another resident with assessed physical aggression behavior (Resident B), which resulted in a resident being choked and a resident being hit for 2 of 2 residents reviewed for abuse (Resident C and Resident D). Findings include: On 2/22/21 at 10:31 a.m., Resident B was observed to be calmly laying on a couch watching television in the orange room (an area to provide Resident B a quiet space). Interview, at that time, Resident B indicated he was moving to California next week to live with his family. On 2/23/21 at 11:30 a.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. [MEDICAL CONDITION] and mood disorder), and [MEDICAL CONDITION] disorder. […]

• No harm, potential for more than minimal, patternF812Mar 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 kitchen observations. Food was not discarded by the discard date and food was stored under the condenser fan. This had the potential to affect 85 of 102 residents who were served food from the kitchen. Findings include: On 3/28/25 at 10:30 a.m., during a follow-up tour of the kitchen with the Dietary Manager (DM), the following was observed: - The walk in refrigerator had a container of liquid salad dressing with an open date of 1/12/25 and a discard date of 2/12/25. - The walk in freezer had an open box of cheddar biscuits directly under the condenser fan, there was ice accumulation noted on the fan directly above the box of food. […]

• No harm, potential for more than minimal, isolatedF552May 13, 2026

  Based on interview and record review, the facility failed to ensure residents were provided the informed consent prior to an increase or a start of a psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 13 and 23)Findings include: 1. On 5/13/26 at 11:55 a.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, dementia with psychotic behaviors and anxiety. The care plan, dated 10/30/25, indicated Resident 13 received psychotropic medication. The intervention was to educate the resident's family about the risks, the benefits and the potential adverse side effects of the prescribed medication, and to obtain the consent as indicated. […]