Bedford Post Acute: Fall Prevention Failure - PA
Thirteen days later, she fell again.
A nurse aide named in the inspection report as Nurse Aide 1 heard a crash from Resident 1's room at approximately 4:43 a.m. on August 14. She went in and found the resident lying on her back on the floor, her head resting against her rollator walker, her shoes sitting loose by her feet. The resident, who is cognitively impaired and has a diagnosis of Alzheimer's dementia, was unable to explain why she had been up and moving at that hour. Investigators concluded she was most likely trying to reach the bathroom, lost her footing, and fell.
There was no documentation that she was wearing non-skid socks. The Director of Nursing, interviewed by federal inspectors on September 3, 2025, confirmed it: the resident was not wearing non-skid socks at the time of her fall on August 14.
The intervention that staff had written into her care plan after the first fall had not been carried out.
Bedford Post Acute's own fall management policy, dated February 14, 2025, describes a clear process. After a fall, the interdisciplinary team reviews what happened, discusses interventions with the resident or their representative, documents those interventions in the care plan and in a progress note, and updates the care Kardex. The policy exists precisely for situations like this one.
The resident's quarterly assessment, completed July 23, 2025, showed she was independent with transfers and walking, occasionally incontinent of urine, receiving therapy, and had already experienced one fall since her prior assessment. She was living with Alzheimer's dementia and moving through her room on her own at night.
The facility knew the risk. They wrote down what to do about it. Then it didn't get done.
Federal inspectors cited Bedford Post Acute for failing to ensure fall and injury prevention interventions were in place, a deficiency classified as causing minimal harm or potential for actual harm. The citation covers one of three residents whose records were reviewed during the September 3 complaint inspection.
The classification of minimal harm is a regulatory designation. What it describes is a woman with Alzheimer's who fell twice in less than two weeks, once landing with her head against her walker in the dark, before 5 in the morning, alone on the floor of her room.
Non-skid socks are not a complex intervention. They cost very little. They do not require a physician's order or specialized training to put on a resident before she goes to sleep. The gap between writing an intervention into a care plan and making sure it actually happens on the overnight shift is, in this case, the entire story.
The Director of Nursing did not dispute the finding. The socks were not on her feet.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bedford Post Acute from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BEDFORD POST ACUTE in BEDFORD, PA was cited for violations during a health inspection on September 3, 2025.
Thirteen days later, she fell again.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.