Pennsylvania Department of Health
BEDFORD SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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BEDFORD SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  94 surveys for this facility. Please select a date to view the survey results.

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BEDFORD SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on March 27, 2024, it was determined that Bedford Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on review of policies, resident council meeting minutes, and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received and failed to ensure that grievances were responded to in a timely manner for one of seven residents reviewed (Resident 4), and failed to include the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, or any corrective action taken or to be taken by the facility as a result of the grievance for one of seven residents reviewed (Resident 7).

Findings include:

The facility's policy regarding grievances/complaints, dated February 28, 2024, indicated that upon receipt of the grievance/concern, the grievance/concern form will be initiated by the staff member receiving the concern and documented on the grievance/concern log. The department manager will contact the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective actions if needed, and notify the person filing the grievance of resolution within 72 hours.

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2024, revealed that the resident was alert and oriented and able to make her needs known.

Resident Council Meeting Minutes, dated February 16, 2024, revealed that Resident 4 presented a concern with the lack of staff to get residents into bed at night. The resident indicated that she addressed it with the Director of Nursing.

The facility's grievance/complaint logs, dated January 1, 2024, through March 20, 2024, revealed no documented evidence that Resident 4's concern regarding the lack of staff to get residents into bed at night was listed on the facility's grievance/complaint log and/or that the concern was investigated.

Interview with the Director of Nursing on March 27, 2024, at 1:55 p.m. revealed that an official grievance form was not completed regarding Resident 4's concern regarding the lack of staff to get residents into bed at night. She indicated that when she came in the next morning, she saw Resident 4, who was still upset, so she talked to her and the resident told her that she was upset that the staff does not like her. When she asked the resident why she felt that way, the resident told her it was because staff would not put her to bed that evening when she wanted to go to bed. The Director of Nursing confirmed that she did not complete a further investigation into the concerns of the resident at that time.

A grievance form for Resident 7, dated March 5, 2024, revealed that the resident presented a concern regarding long call bell times at 3:00 a.m. and not getting his pain medications.

There was no documented evidence that Resident 7's complaint/grievance was thoroughly investigated, including interviews and/or written statements from the staff who worked during the shift in question, and whether the resident was receiving his pain medications as ordered. There was also no documented evidence of a summary of the findings or conclusion regarding the resident's concerns or corrective actions taken or to be taken by the facility because of the grievance.

Interview with the Nursing Home Administrator on March 27, 2024, at 3:50 p.m. confirmed that there was no documented evidence that Resident 7's grievance included interviews with staff regarding the mentioned concerns and no summary of the findings or corrective actions taken or to be taken by the facility.

28 Pa. Code 201.29(c.3)(4) Resident rights.





 Plan of Correction - To be completed: 05/22/2024

Resident 4 provided education regarding her option to voice concerns and file a grievance at any time. Resident 7 is no longer a resident in the facility.
Grievances in the last 30 days were reviewed by the Nursing Home Administrator (NHA) to ensure proper completion and follow through on concerns.
The NHA reeducated the Department Managers on the facility's grievance guidelines.
The Social Services Director/ designee to conduct Quality Improvement (QI) monitoring to ensure ongoing efforts to resolve grievances. Monitor conducted via weekly grievance reviews times 4 weeks X 4 weeks, biweekly X 1 months, then monthly as needed. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of seven residents reviewed (Resident 2).

Findings include:

A facility policy regarding plans of care, dated February 28, 2024, revealed that the care plan must be customized to each individual patient's preferences and needs. The care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 20, 2024, revealed that the resident was understood, could understand, and had diagnoses that included seizures and traumatic brain injury (TBI - an injury that affects how the brain works). A care plan for the resident, dated March 4, 2024, revealed that the resident had an activities of daily living (ADL) self-care deficit, and that the resident transferred independently. A care plan dated, October 8, 2023, revealed that the resident was non-weight bearing to the bilateral lower extremities, required assistance, and was to be transferred with a mechanical lift (used for a resident who is unable to assist with transferring in and out of a bed or wheelchair or shower chair) with a large size sling.

A nursing note for Resident 2, dated December 8, 2023, indicated that the resident was ambulating (walking) independently now.

Observations of Resident 2 on March 27, 2024, at 10:25 a.m. revealed that the resident was transferring by herself in and out of bed independently, as well as ambulating throughout the facility independently.

There was no documented evidence that Resident 2's care plan was updated/revised/resolved to indicate that the resident did not require the use of a mechanical lift for her transfers.

Interview with the Director of Nursing on March 27, 2024, at 1:59 p.m. confirmed that Resident 2's care plan should have been updated to show that the use of a mechanical lift for her transfer had been resolved.

28 Pa. Code 211.12(d)(5) Nursing Services.




 Plan of Correction - To be completed: 05/22/2024

All residents of the facility have the potential to be affected. Resident 2 care plan was reviewed, updated and revised at the time of discovery.

The Director of Nursing (DON) and designee audited all current resident care plans, which was completed on 4/10/24 to ensure a resident centered, comprehensive care plan was developed and implemented for current transfer status, with corrective action upon discovery.

All licensed nursing staff will be reeducated by the DON/designee on updating care plans to reflect the current status of transfer ability.

The DON/designee will audit care plans for all new admissions/readmissions, change in condition, and quarterly care plans to ensure transfer status is accurate according to resident's current level of functioning, weekly x 4 weeks then monthly x 2 months.

Results of audits will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC.

211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the day shift for 11 of 21 days, failed to ensure a minimum of one nurse aide per 12 residents on the evening shift for 20 of 21 days, and failed to ensure a minimum of one nurse aide per 20 residents on the overnight shifts for nine of 21 days (24-hour periods) reviewed.

Findings Include:

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one nurse aide per 18 residents on February 29, 2024; provided one nurse aide per 17 residents on March 15, 2024; provided one nurse aide per 15 residents on March 9, 10, and 16, 2024; provided one nurse aide per 14 residents on March 12, 2024; and provided one nurse aide per 13 residents on February 25, 26, and 28, and March 4, and 8, 2024, during the day shift.

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one nurse aide per 20 residents on March 16, 2024; provided one nurse aide per 18 residents on March 2, 2024; provided one nurse aide per 17 residents on February 26, and March 9, 10, and 13, 2024; provided one nurse aide per 16 residents on March 1, and 12, 2024; provided one nurse aide per 15 residents on March 6, 7, 8, 11, 14, and 15, 2024; provided one nurse aide per 14 residents on March 5, 2024; and provided one nurse aide per 13 residents on February 27, 27, 28, and 29, and March 3 and 4, 2024, during the evening shift.

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one nurse aide per 30 residents on March 6, and 15, 2024; provided one nurse aide per 27 residents on March 4, 2024; provided one nurse aide per 26 residents on February 25, and 27, 2024; provided one nurse aide per 24 residents on March 14, 2024; provided one nurse aide per 23 residents on March 12, 2024; provided one nurse aide per 22 residents on March 1, 2024; and provided one nurse aide per 21 residents on February 28, 2024, during the overnight shift.

Interview with the Nursing Home Administrator on March 27, 2024, at 1:50 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.





 Plan of Correction - To be completed: 05/22/2024


1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Nursing Home Administrator (NHA) re-educated the scheduler on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The NHA or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via review of Daily Schedules weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.



211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interviews, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day on the day shift for 18 of 21 days, failed to ensure a minimum of one LPN per 30 residents on the evening shift for 11 of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shifts for 12 of 21 days (24-hour periods) reviewed.

Findings Include:

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one LPN per 62 residents on March 8, 2024; provided one LPN per 60 residents on March 6, 2024; provided one LPN per 57 residents on March 1 and 5, 2024; provided one LPN per 55 residents on March 2 and 4, 2024; provided one LPN per 53 residents on February 28, 2024; provided one LPN per 52 residents on February 25, 2024; provided one LPN per 31 residents on March 7, 2024; provided one LPN per 30 residents on March 9, 10, 14, 15, and 16, 2024; provided one LPN per 29 residents on March 12, 2024; provided one LPN per 27 residents on February 29, 2024, and provided one LPN per 26 residents on February 26 and 27, 2024, during the day shift.

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one LPN per 62 residents on March 8, 2024; provided one LPN per 61 residents on March 9 and 10, 2024; provided one LPN per 60 residents on March 6, 11, and 16, 2024; provided one LPN per 57 residents on March 5, 2024; provided one LPN per 56 residents on March 2, 2024; provided one LPN per 55 residents on February 29, 2024; provided one LPN per 53 residents on February 28, 2024; and provided one LPN per 52 residents on February 27, 2024, during the evening shift.

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided one LPN per 61 residents on March 10, 2024; provided one LPN per 60 residents on March 6, 14, and 15, 2024; provided one LPN per 59 residents on March 12, 2024; provided one LPN per 57 residents on March 1, 2024; provided one LPN per 55 resident on February 29, 2024, and March 3 and 4, 2024; provided one LPN per 53 resident on February 28, 2024; and provided one LPN per 29 residents on February 25 and 27, 2024, during the overnight shift.

Interview with the Nursing Home Administrator on March 27, 2024, at 1:50 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.




 Plan of Correction - To be completed: 05/22/2024

1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Nursing Home Administrator (NHA) re-educated the scheduler on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The NHA or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via review of Daily Schedules weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.


211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:


Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for 21 of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the days of February 25 through March 16, 2024, revealed that the facility provided only 2.81 hours of direct care for each resident on February 27, 2024; 2.76 hours of direct care for each resident on February 26, 2024; 2.70 hours of direct care for each resident on March 5, 2024; 2.61 hours of direct care for each resident on March 6 and 7, 2024; 2.59 hours of direct care for each resident on February 25, 2024; 2.58 hours of direct care for each resident on March 3, 2024; 2.57 hours of direct care for each resident on March 1, 2024; 2.54 hours of direct care for each resident on March 11 and 12, 2024; 2.50 hours of direct care for each resident on March 14, 2024; 2.47 hours of direct care for each resident on February 28, 2024; 2.43 hours of direct care for each resident on February 29, 2024; 2.38 hours of direct care for each resident on March 4 and 16, 2024; 2.32 hours of direct care for each resident on March 15, 2024; 2.27 hours of direct care for each resident on March 10, 2024; 2.23 hours of direct care for each resident on March 8, 2024; and 2.20 hours of direct care for each resident on March 9, 2024.

Interview with the Nursing Home Administrator on March 27, 2024, at 1:50 p.m. confirmed that staffing was below the required minimum number of nursing care hours for the days listed above.





 Plan of Correction - To be completed: 05/22/2024

1. The facility cannot retroactively correct nursing staffing hours and ratios.
2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department.
3. The Nursing Home Administrator (NHA) re-educated the scheduler on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy.
4. The NHA or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via review of Daily Schedules weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.




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