Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding medication errors, specifically related to anticoagulant medications for residents.
Complaint Details
The visit was complaint-related, confirming a medication error for Resident #3 who did not receive anticoagulation therapy from 7/22/24 to 8/29/24. The error was identified on 8/28/24.
Findings
The facility failed to ensure that one resident out of three reviewed received proper anticoagulant medication, resulting in a significant medication error where the resident did not receive Apixaban for over a month. The facility implemented corrective actions including notification, quality assurance meetings, audits, and staff education.
Deficiencies (1)
Failure to ensure a resident was free from significant medication errors related to anticoagulant therapy.
Report Facts
Residents reviewed for anticoagulant medications: 3
Residents affected: 1
Dates medication not received: 39
Date survey completed: Oct 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Staff A interviewed confirming medication error |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 31, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, beneficiary notices, and assessment accuracy at Bedford Hills Center.
Findings
The facility was found deficient in multiple areas including failure to inform residents or their representatives about antipsychotic medication risks, failure to provide timely Medicare/Medicaid beneficiary notices to residents, inaccurate Minimum Data Set (MDS) assessments for several residents, and failure to remove expired medications from stock.
Deficiencies (4)
Failed to inform resident and/or representative of risks and benefits of antipsychotic medication for 1 of 5 residents reviewed.
Failed to ensure residents received timely notice of Medicaid/Medicare coverage and potential liability for services not covered for 2 of 3 residents reviewed.
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status for 3 of 26 residents reviewed.
Failed to ensure expired medications were removed from stock in 1 of 2 medication rooms observed.
Report Facts
Residents reviewed for unnecessary medications: 26
Residents reviewed for beneficiary notices: 3
Residents reviewed for MDS assessment accuracy: 26
Medication rooms observed: 2
Expired medication bottles found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed findings related to antipsychotic medication and expired medications | |
| Minimum Data Set Coordinator | Confirmed findings related to beneficiary notices and MDS assessment inaccuracies | |
| Director of Social Services | Provided information about resident discharge and Medicare services | |
| Administrator | Confirmed facility initiated Medicare Part A discharge and should have issued notices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors involving insulin administration at the facility.
Complaint Details
The complaint investigation found that a resident received an insulin overdose due to staff using the wrong syringe type, resulting in hypoglycemia and hospital transfer. The issue was substantiated with medical record reviews and staff interviews confirming the error.
Findings
The facility failed to ensure residents were free from significant medication errors, resulting in a resident receiving five times the ordered dose of Humulin R U-500 insulin, causing hypoglycemia and hospital observation. The facility subsequently updated policies, provided nurse education, and implemented monitoring and audits for insulin administration.
Deficiencies (1)
Failure to ensure residents remain free from significant medication errors, resulting in a resident receiving an overdose of Humulin R U-500 insulin.
Report Facts
Residents reviewed for insulin use: 3
Residents affected: 1
Insulin overdose factor: 5
Blood glucose readings: 42
Date of insulin overdose: Mar 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Staff B who administered the wrong insulin dose using incorrect syringe | |
| Director of Nursing | Staff A who confirmed the medication error and overdose |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, oral hygiene care, and activities of daily living for residents at the nursing facility.
Findings
The facility failed to follow physician orders and proper medication administration procedures for 2 residents, including failure to remove a Lidocaine patch and improper handling of a dropped medication tablet. Additionally, the facility failed to provide oral hygiene care for one resident who required total assistance.
Deficiencies (3)
Failure to remove Lidocaine External Patch as ordered for Resident #7.
Staff picked up a dropped Anastrozole tablet with bare hands and administered it to Resident #98.
Failure to provide oral hygiene care for Resident #86 who requires total assistance.
Report Facts
Residents observed for medication administration: 4
Residents reviewed for Activities of Daily Living: 1
Medication dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Staff C involved in medication administration for Resident #7 | |
| Licensed Practical Nurse | Staff D involved in medication administration for Resident #98 | |
| Licensed Nursing Assistant | Staff A assigned to Resident #98 and involved in oral hygiene care for Resident #86 | |
| Unit Manager | Staff B interviewed regarding oral hygiene care for Resident #86 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide oral hygiene care to Resident #86 who requires assistance with activities of daily living.
Complaint Details
Complaint investigation related to failure to provide oral hygiene to Resident #86; substantiation indicated by findings.
Findings
The facility failed to provide oral hygiene for Resident #86 after breakfast on 6/27/23, despite documentation indicating oral care was completed. Interviews confirmed the resident is unable to perform oral hygiene independently and requires total staff assistance.
Deficiencies (1)
Failure to provide oral hygiene for Resident #86 who requires assistance with activities of daily living.
Report Facts
Residents affected: 1
Dates oral hygiene completed by resident: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Nursing Assistant | Assigned to Resident #98 and did not provide oral hygiene to Resident #86 on the morning of 6/27/23 |
| Staff B | Unit Manager | Interviewed and confirmed Resident #86 requires total assist for oral hygiene |
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