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Complaint Investigation

Bedford Post Acute

Inspection Date: November 12, 2025
Total Violations 1
Facility ID 395221
Location BEDFORD, PA
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Inspection Findings

F-Tag F0585

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's and their family member's concern for one of three residents reviewed (Resident 2).Findings include: The facility's policy regarding complaint grievances, dated February 14, 2025, revealed that the facility ensures complaints regarding the community were resolved in a timely and appropriate manner for employees or residents who have concerns or complaints. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and had a diagnosis of parkinsonism (syndrome that causes movement symptoms like tremor, stiffness, and slowness of movement).Interview with the Resident 2 on November 12, 2025, at 12:16 p.m. revealed that he was upset when a staff member got water out of the shared bathroom sink for him to drink. He said that he had reported it to staff and also told his power of attorney. Review of Resident 2's clinical record and the facility's grievance logs revealed no concerns related to Resident 2's complaints or the family's complaints about not wanting drinking water that was obtained from the shared bathroom.Interview with Nurse Aide 2 on November 12, 2025, at 3:13 p.m. indicated that she was aware that the family does not want water from the bathroom, and that she had reported the concern to her nurse at the time, but that had been a while ago. Nurse Aide 2 gets water for Resident 2 from the medication cart, medication room, or the pantry.Interview with Nurse Aide 1 on November 12, 2025, at 4:01 p.m. revealed that Resident 2's spouse was upset that water was being obtained from the shared bathroom and not from

the kitchen. Management was informed regarding the concern about the water, but staff still have not been told where they should get the Resident's water.Interview with the Director of Nursing on November 12, 2025, at 4:32 p.m. revealed that the facility was permitted to obtain water from the shared bathroom sink.

The Director of Nursing also indicated that there was no grievance because it was the resident's spouse who reported the concern with the water and felt it was a non-issue because the family has multiple complaints and this did not meet the level for a grievance. 28 Pa. Code 201.29(i) Resident Rights.

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:

📋 Inspection Summary

BEDFORD POST ACUTE in BEDFORD, PA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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.
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