Inspection Reports for
Bedford Care Center of Mendenhall

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 07/31/26.

CI MS# 2986961 was investigated for falls from a lift and F656 and F689 were cited related to this Facility Reported Incident (FRI).

The facility was found not in compliance with multiple requirements including failure to respond to Resident Council concerns about daily bed making, failure to implement an effective infection prevention and control program, failure to develop and implement comprehensive care plans, and failure to ensure residents were transferred using the care planned mechanical lift.

The facility was found not in compliance with state licensure requirements due to failures in safe resident transfer practices and infection control procedures. Specifically, improper use of mechanical lifts for Resident #14 and inadequate infection prevention practices related to medication administration and wound care for Residents #4 and #42 were identified.

The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.

Complaint 2732360 was investigated related to nursing services, neglect, and quality of care. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint survey conducted on 12/15/25 through 12/17/25; the facility was found in compliance with no deficiencies cited.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 1/12/26.

Complaint survey conducted 12/15/25 through 12/17/25; the facility was found in compliance and no deficiencies were cited.

The SA found the facility to be in compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and recommends the facility be placed back in compliance effective 1/12/26.

Complaint Investigations MS #2694683 and MS #2690680 involved an allegation that a CNA had fallen onto a resident during care; no citations were issued for these complaints. Complaint MS #2690000 involved a medication error and resulted in citation F760.

The facility was found not in compliance due to a significant medication error involving two residents. Resident #1 missed six doses of prescribed antibiotic therapy due to a medication reconciliation error, resulting in rehospitalization for wound infection and dehiscence. Resident #2 received duplicate doses of antihypertensive medications, which could have caused a dangerous decrease in blood pressure, but no adverse effects were noted.

The complaint investigation substantiated medication errors for Resident #1 and Resident #2. Resident #1 missed six doses of doxycycline due to a medication entry error, leading to rehospitalization for wound infection and dehiscence. Resident #2 received double doses of antihypertensive medications due to failure to sign the EMAR and nurse assignment issues, requiring physician notification and monitoring.

The facility failed to ensure residents were free from significant medication errors, resulting in missed doses of prescribed antibiotic therapy and duplicate administration of antihypertensive medications. These errors affected two of four sampled residents and led to rehospitalization and close monitoring.

Complaint 2569531 investigated related to resident neglect and quality of care; no deficiencies were cited and the facility was found in compliance.

The SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

The State Agency is recommending that the facility be placed back in compliance effective 03/21/25. No deficiencies were cited in this desk review.

The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights and infection control. The facility failed to ensure residents' rights were honored, including allowing Resident #44 to get out of bed as requested and providing preferred bedtime snacks. Infection control practices were deficient, including improper use of enhanced barrier precautions and poor hand hygiene.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in resident self-determination, comprehensive care planning, professional standards of care, and infection prevention and control.

The facility failed to honor resident rights by not facilitating resident self-determination, failed to develop and implement comprehensive care plans for some residents, did not ensure physician orders for enabling devices, and failed to follow infection prevention guidelines including improper use of enhanced barrier precautions and hand hygiene.

No deficiencies were cited during this survey for emergency preparedness or Life Safety Code compliance.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 9/10/24.

Complaint survey conducted 8/01/24 through 8/05/24; the facility was found in compliance with no deficiencies cited.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 9/10/24.

CI MS #25877 investigated resident rights and accidents/hazards. Deficiencies were cited including Immediate Jeopardy related to inadequate supervision causing a third-degree burn. The IJ was removed after corrective actions.

The facility was found not in compliance with requirements related to resident self-determination, comprehensive care planning, and accident hazards. Resident #1 was allowed to use chewing tobacco despite facility policy, but staff took it away causing distress. Resident #1 sustained a third-degree burn from spilling hot coffee due to inadequate supervision and lack of care plan interventions. The facility took corrective actions and removed the Immediate Jeopardy prior to exit.

Two complaint investigations (CI MS #25877 and CI MS #24339) were conducted. No deficiencies were cited related to CI MS #24339. CI MS #25877 was substantiated with deficiencies cited, including an Immediate Jeopardy related to inadequate supervision resulting in a resident burn injury.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and cited for two deficiencies. One deficiency involved failure to ensure a resident's right to self-determination related to tobacco use, causing distress to the resident. The other deficiency involved failure to provide adequate supervision to prevent a third-degree burn from hot coffee to a resident with impaired cognition.

The complaint investigation was triggered by concerns about the facility's enforcement of its tobacco-free policy, which led to a resident's tobacco being taken away without proper notice, causing emotional distress. Additionally, the investigation included an incident where the resident sustained a third-degree burn from spilling hot coffee due to inadequate supervision and safety measures. The family filed a grievance on 07/11/24, and the State Agency validated the facility's removal plan and corrective actions by 08/05/24.

The facility failed to respect a resident's right to self-determination by improperly enforcing a tobacco-free policy, causing distress to the resident. Additionally, the facility failed to develop adequate care plans and provide sufficient supervision to prevent a third-degree burn from hot coffee, resulting in immediate jeopardy to resident health and safety.

The complaint investigation substantiated that Resident #1 was improperly transferred by CNA #1 without using the required full body lift with two-person assist, resulting in fractures and injury. The CNA was terminated. Resident #1 later died on 11/10/2023, with death certificate listing Failure to Thrive and Dementia as cause of death.

The facility failed to implement the care plan for a two-person transfer using a full body lift, causing fractures to Resident #1's left tibia, fibula, and femur. The responsible CNA was terminated, and the facility implemented corrective actions including staff in-services and transfer audits.

CI MS #23522 involved a Facility Self-Reported Incident regarding an improper transfer causing fractures to Resident #1. The complaint was substantiated with deficiencies cited at F0656 and F0689.

The facility was found to have deficiencies at F0656 and F0689 related to failure to implement the care plan for a two-person full body lift transfer, resulting in injury to Resident #1. The facility was determined to be in Past Non-Compliance based on corrective actions implemented between 11/09/23 and 11/12/23.

The SA found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and recommends the facility be placed back in compliance effective 10/12/23.

The SA found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/12/23.

The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights and infection control. Issues included call lights not within reach, lack of privacy during resident council meetings, absence of posted complaint contact information, posting of medical signage visible to visitors, and improper medication administration practices.

The facility was found not in compliance with multiple federal requirements including call light accessibility, resident group privacy, required notices, personal privacy, tube feeding management, respiratory care, nurse staffing posting, medication storage, infection control, and immunization administration.

The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, lack of private meeting space for resident council, failure to post grievance contact information, privacy violations with medical information signage, improper medication administration practices, failure to post nurse staffing information, failure to discard expired medications, inadequate infection control during medication administration, failure to provide requested influenza, pneumococcal, and COVID-19 vaccinations, and failure to post oxygen cautionary signage.

Complaint number CI MS#20933 investigated for maintenance of medical equipment; no deficiencies cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited during this complaint investigation.

CI MS#20933 investigated maintenance of medical equipment and was not substantiated; no deficiencies were cited.

The facility was found to be in compliance with Medicare and Medicaid requirements. No deficiencies were cited during this complaint investigation.

Complaint number CI MS#20668 was investigated for physical environment and no deficiencies were cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.

Complaint Investigation (CI), MS #20668 was investigated for a safe environment and no deficiencies were cited.

The facility was found to be in compliance with infection control regulations and Medicare and Medicaid requirements. No deficiencies were cited related to infection control or the complaint investigation.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

Complaint investigation CI MS#26995 was reviewed and found to be substantiated previously, but the facility was found in compliance at this desk review with no deficiencies cited.

The State Agency found the facility in compliance and recommended it be placed back in compliance effective 11/11/22. No deficiencies were cited in this document.

CI MS#19449: The complaint alleged inadequate grooming related to showering assistance. The SA substantiated the complaint and cited deficiency F677.

The facility was found to be out of compliance with bathing and showering assistance for dependent residents. The surveyor substantiated the complaint that residents did not consistently receive scheduled showers, affecting three of five residents reviewed.

CI MS#19449 substantiated for Quality of Care/Treatment related to adequate grooming with deficiency cited.

M610 - The facility failed to ensure residents dependent on staff for showering received those services as scheduled for three of five residents reviewed. Multiple residents and family members reported not receiving showers as scheduled, and documentation showed missed bathing interventions. The facility acknowledged ongoing issues despite plans to improve shower assistance.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

Complaint Investigation CI MS 18560 for sexual abuse was not substantiated and no deficiencies were cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and there were no deficiencies cited.

Complaint Investigation CI MS #18517 substantiated related to an elopement incident where the facility failed to provide adequate supervision to prevent Resident #1 from leaving the facility unsupervised. Deficiency cited.

The facility failed to provide adequate supervision to prevent the elopement of Resident #1 on 2/07/22. Resident #1 exited the facility unnoticed and was found at the local hospital approximately 36 minutes later. The facility implemented corrective actions including one-on-one supervision and installation of window stops to prevent further incidents.

The facility was found to be in substantial compliance as of 5/31/21.

The facility failed to accurately code the admission Minimum Data Set (MDS) for one resident by incorrectly marking Aspirin as an anticoagulant. Additionally, the facility failed to ensure one resident received oxygen at the ordered flow rate, initially administering oxygen at 1.5 liters per minute instead of the ordered 3 liters per minute.

CI MS #17727: The complaint investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Water not Offered, Client Services not Performed Per POC and Physicians Orders, Responsible Party not Notified of Residents Change in Condition, Resident not Turned Timely and Nursing Services.

The facility was found not in compliance with state minimum standards due to failure to ensure a resident received oxygen at the ordered flow rate. The complaint investigation was unsubstantiated with no deficiencies cited.

CI MS #17727 The result of the complaint investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Water not Offered, Client Services not Performed Per POC and Physicians Orders, Responsible Party not Notified of Residents Change in Condition, Resident not Turned Timely and Nursing Services.

Two deficiencies were cited related to inaccurate resident assessments and improper respiratory care. The facility failed to accurately code the admission Minimum Data Set for one resident and failed to ensure a resident received oxygen at the ordered flow rate.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

CI MS #15446 was substantiated for ants in the facility with deficiencies cited at F925.

The facility failed to maintain an effective pest control program as ants were present in the facility, including four live ant beds and seven dead ant beds on the grounds. Resident #1 had multiple ant bites and was treated with antibiotic ointment.

CI MS#15106: A complaint investigation was conducted and substantiated with no deficiencies cited.

The complaint investigation was substantiated with no deficiencies cited.

The facility was found not in compliance with Medicare and Medicaid requirements due to deficiencies in care planning, services by qualified persons, pressure sore treatment, food service sanitation, hospice coordination, and smoke detection. Deficiencies involved failure to revise care plans accurately, inconsistent wound care, lack of hair coverings in dietary, absence of a designated hospice coordinator, and missing smoke detectors in corridors.