Bedford Wellness & Rehabilitation
BEDFORD WELLNESS & REHABILITATION in BEDFORD, TX — inspection on November 17, 2025.
Found 3 citations. 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
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bedford Wellness & Rehabilitation
2001 Forest Ridge Dr Bedford, TX 76021
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bedford Wellness & Rehabilitation
2001 Forest Ridge Dr Bedford, TX 76021
SUMMARY STATEMENT OF DEFICIENCIES
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] 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] 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.'
Facility ID: