Bedford Wellness & Rehabilitation

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the resident penis could cause skin problems as well as infections. She stated they were supposed to clean all of the areas anytime they did incontinence care. In an interview with the DON on 11/17/225 at 11:15 a.m. she stated any time the staff did incontinence care on a male they were supposed to clean the penis and if they were uncircumcised they had to pull the foreskin back to clean around the meatus. She stated failure to do perform correct incontinence care could lead to an increased risk of urinary tract infections.

She stated they would be starting peri-care skills checks immediately. Record review of the facility's policy titled, Perineal Care, dated June 2020, reflected, .Put on gloves. Wash the pubic area.For male residents.Wash the penis from the ureteral opening or tip of the penis. Pull back the foreskin on uncircumcised males and clean under it. Wash the scrotum, pay attention to skin folds, rinse and dry.Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bedford Wellness & Rehabilitation

2001 Forest Ridge Dr Bedford, TX 76021

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

used to provide peri care, CNA C placed a clean brief under the resident and rolled her back and fastened

the brief. Staff then repositioned the resident, covered her up still wearing soiled gloves. Both staff then removed their gloves and gowns and washed their hands. In an interview with CNAs C and D on 11/17/25 at 10:10 a.m. both stated they were supposed to perform hand hygiene before incontinent care and once

they finished. CNA C then stated she should have also performed glove change and hand hygiene when

she finished cleaning the resident, before putting on the clean brief and repositioning her. They both stated

the risk of not performing hand hygiene and glove changes was the spread of germs and infections. In an

interview with the DON on 11/17/225 at 11:15 a.m. she stated it was the expectation for the staff to perform hand hygiene before care, after each glove change, and before leaving the room. She stated they were also to change their gloves when soiled, before moving to the clean part of care. She stated they would be starting peri-care skills checks immediately as well as hand hygiene training. Record review of the facility's' policy titled, Hand hygiene reflected, .The facility considers hand hygiene the primary means to prevent the spread of infections.Facility staff are trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Facility staff.must perform hand hygiene procedures in the following circumstances.Immediately upon entering a resident occupied area.regardless of glove use.Immediately upon exiting a resident occupied area.Hand hygiene is always the final step after removing and disposing of personal protective equipment.The use of gloves does not replace hand hygiene procedures. Record review of the facility's policy titled, Perineal Care, dated June 2020, reflected, .Put on gloves. Wash the pubic area.Turn resident to side.Remove gloves. Wash hands or use alcohol-based sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, etc.) .Put on clean gloves. Clean and return all equipment to its proper place. Place soiled linen in proper container. Remove gloves. Wash hands.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bedford Wellness & Rehabilitation

2001 Forest Ridge Dr Bedford, TX 76021

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay

the call directly to a staff member or a centralized staff work area for one of five residents (Resident#3) reviewed for residents' call system. The facility failed on 11/16/25 to ensure the call light system was inaccessible for Resident #3. The call light was out of reach and under the positioning rail. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when

they needed support for daily living. Findings included: Record review of Resident #3's face sheet undated reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses of Metabolic Encephalopathy (brain dysfunction caused by a systemic illness or metabolic imbalance that affects brain function), glaucoma (group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve) and heart failure. Record review of Resident #3's quarterly MDS assessment dated [DATE REDACTED] reflected Resident #3 had a BIMS of 15 indicating

she was cognitively intact. Resident #3 required partial/moderate assistance with ADLs of transfers and toileting. Resident #3 was frequently incontinent of bowel/bladder. Record review of Resident #3's comprehensive care plan reflected Resident #3 revised on 09/24/25 had an actual fall with injury due to poor balance and unsteady gait. Resident #3 is at risk for falls related to gait/balance problems. Intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation and Interview on 11/16/25 at 2:13 PM revealed Resident #3 was yelling and calling out from her room for help. There was no facility staff in the hall. Resident #3 was lying in her bed and her call button was under the right positioning side rail. Resident #3 stated she needed help and told surveyor thank you I had no way of getting help other than yelling out. Resident #3 stated she could not use her call button if it was not near her and she needed assistance. She stated she was dependent on staff for assistance and was bed bound. Interview and observation on 11/16/25 at 2:16 PM with Med Aide E revealed Resident #3's call button was not within reach and should have been within reach. Observation revealed Med Aide E moved the call button within reach of Resident #3. Resident #3 stated she needed assistance from a nurse. Interview on 11/16/25 at 2:18 PM with LVN F revealed Resident #3's call button should be within reach of resident to use when she needs assistance from staff. LVN F stated Resident #3 was dependent on staff for assistance. Interview on 11/17/25 at 11:21 AM with DON revealed call buttons should be within reach of residents so they can get assistance and help when needed. She stated the risk to a resident not having a call button within reach could be a delay in getting assistance from staff. Review of facility's policy Communication - Call System last revised June 2020 reflected To provide a mechanism for residents to promptly communicate to nursing staff. The facility will provide a call system to enable residents to alert the nursing staff from their rooms.Call cords will be placed within the resident's reach in

the resident's room.'

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet