Bedford Post Acute
BEDFORD POST ACUTE in BEDFORD, PA — inspection on September 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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