Bedford Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that
the facility failed to ensure that fall/injury prevention interventions were in place for one of 3 residents reviewed (Resident 1).Findings include: A facility policy for fall management, dated February 14, 2025, indicated that the interdisciplinary team reviews falls. The team will discuss and care plan recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the care plan and progress note. The care plan will be reviewed and/or revised as indicated. The care Kardex will be updated as appropriate. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 23, 2025, revealed that the resident was cognitively impaired, was independent with transfers and ambulation, was occasionally incontinent of urine, received therapy, had one fall since her prior assessment with no injury, and had a diagnosis of Alzheimer's dementia. A nursing note for Resident 1, dated August 1, 2025, at 1:34 a.m., revealed that the resident was sitting on the floor at the foot of her bed.
She stated that she slipped and landed on her buttocks. New interventions included recommendations to wear non-skid socks at bedtime. A nursing note for Resident 1, dated August 14, 2025, at 5:06 a.m., revealed that the resident was found in her room lying on the floor on her back with her legs pointed towards her recliner chair. A fall investigation revealed that the resident was unable to describe why she was ambulating so early in the morning. It was determined at the conclusion of the investigation that the resident was most likely ambulating to the bathroom, lost her footing and sustained a fall. A witness statement from Nurse Aide 1, dated August 14, 2025, at 5:06 a.m. revealed that on the morning of August 14, 2025, at approximately 4:43 a.m., she heard a crash in Resident 1's room. Upon entering the resident's room, she saw the resident lying on her back on the floor with her head against her rollator walker and her shoes were by her feet on the floor. There was no documented evidence that the resident was wearing non-skid socks at the time of her fall. Interview with the Director of Nursing on September 3, 2025, at 2:38 p.m. confirmed that Resident 1 was not wearing non-skid socks at the time of her fall on August 14, 2025.28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BEDFORD POST ACUTE in BEDFORD, PA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BEDFORD, PA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BEDFORD POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.