Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident who was always incontinent of urine and bowel did not receive appropriate perineal care during an incontinence episode. Two CNAs failed to clean the resident's penile shaft and did not pull back the foreskin to clean the meatus area, as required by facility policy. The resident expressed concern that not all of the bowel movement was removed, and interviews with staff confirmed that proper care steps were missed.
Staff failed to perform proper hand hygiene and glove changes during incontinence care for two residents with complex medical conditions. In both cases, CNAs did not sanitize their hands before donning gloves, between glove changes, or before leaving the room, and used soiled gloves to handle clean items and reposition residents. These actions were contrary to facility policy and were acknowledged by the staff involved during interviews.
A bed bound resident with a history of falls, metabolic encephalopathy, glaucoma, and heart failure was found unable to access her call light, which was placed under a side rail and out of reach. The resident was observed calling out for help, and staff confirmed the call button should have been accessible, as required by facility policy and the resident's care plan.
A social worker without state-approved feeding assistant training assisted a resident with moderate cognitive impairment and neurological conditions during a meal. The staff member was observed feeding the resident, despite not having completed the required training, and the facility lacked a policy or training for non-nursing staff on assisted feeding.
A facility failed to create a baseline care plan within 48 hours for a resident with acute kidney failure and an indwelling Foley catheter. The absence of a care plan meant there were no documented interventions for the resident's conditions, as observed during a record review and an incident involving a cloudy catheter collection bag. The DON confirmed that the interdisciplinary team did not complete the plan within the required timeframe, contrary to the facility's Care Planning policy.
A facility failed to include enteral feeding in a resident's comprehensive care plan. The resident, with conditions such as hemiplegia and diabetes, had orders for enteral feeding, but the care plan lacked specific goals and interventions. The DON acknowledged the omission, which contradicted the facility's policy requiring comprehensive care plans to describe necessary services for residents' well-being.
A resident on Enhanced Barrier Precaution did not receive proper infection control measures during catheter care. RN A and ADON B failed to wear gowns and did not perform aseptic technique, as required by the facility's policies. The oversight was confirmed through staff interviews, highlighting a lapse in adherence to infection prevention protocols.
A medication cart was left unlocked and unattended with keys on top, due to an LVN being distracted by assisting a CNA. This breach in protocol was against the facility's policy, which requires medication carts to be locked and keys secured by authorized personnel.
Two residents experienced neglect due to inadequate transportation services, resulting in one resident waiting over four hours after a medical appointment, missing a meal and pain medication, and another resident missing and being late to appointments due to van issues and scheduling delays. These incidents were linked to the facility's insufficient transportation resources and lack of effective communication and tracking systems.
A resident with severe cognitive impairment and multiple medical conditions was found with a foley catheter bag lying on the floor, contrary to the care plan and infection control policies. The LVN corrected the issue upon observation, and both the DON and CNA acknowledged the infection risk. The facility's policy emphasized keeping collection bags off the floor to prevent infections.
Failure to Provide Proper Perineal Care for Incontinent Male Resident
Penalty
Summary
A deficiency occurred when a male resident who was always incontinent of urine and bowel did not receive appropriate perineal care during an incontinence episode. The resident, who was dependent on staff for toileting hygiene and had diagnoses including diabetes, hemiplegia, and viral hepatitis, was observed after waiting several hours for incontinence care. Upon care, two CNAs entered the room and began cleaning the resident, who had a large amount of bowel movement present. During the process, CNA B failed to clean the resident's penile shaft and did not pull back the foreskin to clean the meatus area, as required for uncircumcised males. Additionally, CNA B changed gloves without performing hand hygiene. The resident expressed concern that not all of the bowel movement was removed from his groin area, prompting further cleaning, but the required steps for proper perineal care were still not completed. Interviews with the involved CNAs confirmed that proper perineal care steps were missed, specifically the cleaning of the penis and foreskin. The facility's policy required staff to wash the penis from the ureteral opening, pull back the foreskin on uncircumcised males, and clean under it, which was not followed in this instance. The DON also confirmed that these steps were mandatory and that failure to perform them could lead to infection. The deficiency was identified through observation, interview, and record review, and was limited to one resident reviewed for catheter and incontinence care.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not performing proper hand hygiene during incontinence care for two residents. For the first resident, a male with diagnoses including diabetes, hemiplegia, and viral hepatitis, two CNAs entered the room to provide care. Both CNAs donned gloves and gowns, but neither performed hand hygiene before putting on gloves. During the care process, gloves were changed without hand hygiene, and one CNA left the room with trash without sanitizing her hands. The resident expressed concern that not all soiling was removed from his groin area, and both CNAs later acknowledged missing required hand hygiene steps during the procedure. For the second resident, a female with seizures, hemiplegia, and mild cognitive impairment, two CNAs sanitized their hands before entering the room and donned gloves and gowns. However, during perineal care, one CNA used the same gloves to clean the resident and then to place a clean brief and reposition her, without changing gloves or performing hand hygiene between these steps. Both CNAs only removed their gloves and washed their hands after completing all care and repositioning tasks, contrary to facility policy. Interviews with the involved CNAs confirmed their awareness of the required hand hygiene protocols, including performing hand hygiene before care, after glove changes, and before leaving the resident's room. Facility policies reviewed emphasized the importance of hand hygiene as the primary means to prevent infection, specifying that glove use does not replace hand hygiene and that hand hygiene must be performed at key points during resident care. Despite this, the observed failures in hand hygiene and glove changes during incontinence care led to the cited deficiency.
Call Light System Inaccessible for Bed Bound Resident
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be inaccessible, as the call button was located under the right positioning side rail and out of the resident's reach. The resident, who was bed bound and dependent on staff for assistance, was observed yelling and calling out for help because she could not access the call button. Staff interviews confirmed that the call button should have been within the resident's reach, and facility policy requires call cords to be placed within reach to enable residents to alert nursing staff from their rooms. The resident involved had a history of metabolic encephalopathy, glaucoma, heart failure, and was at risk for falls due to poor balance and unsteady gait. Her care plan specifically included the intervention to ensure the call light was within reach and to encourage its use for assistance. Despite these documented needs and interventions, the call system was not accessible at the time of the surveyor's observation, resulting in the resident being unable to summon help except by yelling.
Untrained Staff Assisted with Resident Feeding
Penalty
Summary
A deficiency occurred when a social worker, who had not completed a state-approved feeding assistant training course, assisted a resident with eating. The resident, an elderly female with Parkinson's Disease, generalized anxiety disorder, and essential tremor, was admitted with moderate cognitive impairment and required supervision with eating. During observation, the social worker was seen feeding the resident a tuna sandwich by bringing the food to her mouth, while the resident was unable to feed herself independently due to her condition. Interviews with the social worker, administrator, and DON revealed that the social worker was not trained in feeding assistance and that the facility did not provide specific training on feeding residents to non-nursing staff. The social worker's training record confirmed the absence of a state-approved feeding training course. The administrator and DON stated that only CNAs and nurses received feeding training as part of their competencies, and there was no policy on assisted feeding for other staff.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which included necessary instructions for effective and person-centered care. This deficiency was identified for a resident who was admitted with acute kidney failure and depression, and who required specific care for an indwelling Foley catheter. The absence of a baseline care plan meant that there were no documented interventions or plans for the resident's acute kidney failure or catheter care, as observed during a record review and an incident where a nurse had to change a cloudy catheter collection bag. Interviews with the Director of Nursing (DON) revealed that the interdisciplinary team, including the Assistant Director of Nursing (ADON), dietitian, administration, social worker, activity director, and therapy manager, were responsible for developing the baseline care plan. However, this plan was not completed within the required timeframe, as confirmed by the DON. The facility's Care Planning policy mandates that a person-centered baseline care plan be developed within 48 hours of admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The failure to adhere to this policy could lead to ineffective care and unmet resident needs, as noted by the DON.
Failure to Include Enteral Feeding in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required enteral feeding. The resident, a male with a history of hemiplegia, hemiparesis, type 2 diabetes, and acute kidney failure, was admitted to the facility and had orders for enteral feeding, including bolus feeding five times a day, flushing, and cleansing of the g-tube every shift, as well as an NPO order. Despite these orders, the resident's comprehensive care plan did not include specific goals and interventions related to the enteral feeding. The Director of Nursing (DON) acknowledged in an interview that the enteral feeding should have been included in the comprehensive care plan, as it is essential for ensuring that all staff can provide proper care by referencing the care plan. The facility's policy requires that each resident's comprehensive care plan describe the services needed to maintain the resident's highest practicable well-being and be completed within seven days after the comprehensive admission assessment. However, the care plan for this resident did not meet these requirements, leading to a deficiency in care planning.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for a resident on Enhanced Barrier Precaution (EBP). During an observation, RN A and ADON B did not wear the required Personal Protective Equipment (PPE) while providing catheter care to a resident. Despite a sign indicating EBP at the resident's door, RN A only wore gloves and did not use a gown. Additionally, RN A did not perform aseptic technique when changing the catheter bag, as he failed to disinfect the catheter port and the new inlet tube with an alcohol wipe before connecting them. Interviews with the staff confirmed the oversight, with both RN A and ADON B acknowledging their failure to wear gowns and perform aseptic technique. The Director of Nursing expressed surprise at the lapse, noting that both staff members had been trained in infection control. The facility's catheter care manual and Standard and Enhanced Precaution Policy clearly outlined the need for aseptic technique and PPE use during high-contact resident care activities, which were not adhered to in this instance.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. During an observation, a medication cart was found unlocked with the keys lying on top, unattended by any facility staff. LVN N, who was responsible for the cart, was distracted by assisting a CNA with a blood sugar patient and forgot to lock the cart and take the keys with her. This oversight left the cart vulnerable to unauthorized access. Interviews with LVN N, the DON, and the ADM confirmed the expectation that medication carts should be locked and keys kept secure at all times. The facility's policy on medication storage, dated September 2018, mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. The failure to adhere to these protocols could lead to unauthorized access to medications, posing risks to residents and staff.
Neglect Due to Inadequate Transportation Services
Penalty
Summary
The facility failed to ensure residents were free from neglect, specifically in the case of two residents who experienced significant delays in transportation for medical appointments. One resident, who was wheelchair-bound and had a history of PTSD, was left waiting for over four hours after completing a medical appointment. This delay caused the resident to miss a meal and a scheduled dose of pain medication, leading to psychosocial harm as the resident felt abandoned and experienced increased pain due to prolonged sitting. Another resident faced transportation issues on two consecutive days. On the first day, the resident missed a medical appointment due to a malfunctioning van lift, and on the second day, the resident was an hour late for an appointment. These delays were attributed to the facility's inadequate transportation resources, including only one van and two drivers, which were insufficient to meet the needs of all residents requiring transportation. Interviews with facility staff revealed systemic issues contributing to these deficiencies, such as a lack of communication tools for drivers, insufficient transportation resources, and a lack of a transportation log to track residents' appointments and pick-up times. The facility's transportation manager and drivers highlighted these challenges, noting that the facility's budget cuts had exacerbated the problem by limiting the use of outsourced transportation services.
Infection Control Deficiency Due to Improper Foley Bag Handling
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper handling of a foley catheter bag for a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including West Nile Virus with Encephalitis, Enteropathogenic Escherichia Coli Infection, and Myocardial Infarction, was observed with his foley bag lying on the floor. This was contrary to the care plan which specified that the drainage bag should be kept off the floor to prevent infection. The resident was unable to manage his toileting hygiene independently, requiring full assistance from staff. During observations and interviews, it was noted that the foley bag had been on the floor for at least 45 minutes, as confirmed by a family member. The Licensed Vocational Nurse (LVN) acknowledged the issue and took steps to correct it by wearing protective gloves and reattaching the bag. The Director of Nursing (DON) and a Certified Nursing Assistant (CNA) both recognized the infection control risk posed by the bag being on the floor, emphasizing the responsibility of nursing staff to ensure proper catheter care. The facility's Catheter Care Policy also highlighted the importance of keeping collection bags off the floor to maintain unobstructed urine flow and prevent infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Dora Nursing And Rehabilitation Center | 0.5 mi | — | 0 | 0 |
| Parkwood Village | 1.1 mi | — | 0 | 0 |
| Westpark Rehabilitation And Living | 1.5 mi | — | 9 | 0 |
| Hurst Plaza Nursing & Rehab | 1.6 mi | — | 0 | 0 |
| Forum Parkway Health & Rehabilitation | 1.7 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.