Inspection Reports for
Bedford Nursing and Rehabilitation Center
480 DONALD ST, Bedford, NH, 03110
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 7
Date: Dec 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, PASARR screening, medication administration, CPR procedures, medication storage, infection prevention, and catheter care at Bedford Nursing & Rehabilitation Center.
Findings
The facility was found deficient in accurately reflecting residents' advance directives, completing PASARR screenings within required timeframes, following physician's medication orders, providing CPR according to guidelines, securely storing medications, implementing infection control policies, and properly managing urinary catheter care.
Deficiencies (7)
Failed to ensure residents' advance directives were accurately reflected for 3 residents.
Failed to complete PASARR screening within 40 days for 2 residents requiring long-term care.
Failed to follow physician's orders for medication administration for 1 resident, including failure to notify provider of high blood glucose and holding insulin doses.
Failed to provide CPR in accordance with American Heart Association guidelines for 1 resident, resulting in immediate jeopardy to resident health or safety.
Failed to store medications securely; medication cards were left unsecured on nurses' station counter.
Failed to implement infection control policies properly, including improper disinfection of equipment used for a resident on contact precautions and improper storage of inhaler.
Failed to keep urinary drainage bag off the floor for a resident with an indwelling catheter.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Confirmed code status and CPR findings for Resident #70 and Resident #119 |
| Staff B | Licensed Practical Nurse | Administered insulin doses and reported Resident #119's passing |
| Staff C | Assistant Director of Nursing | Received call about Resident #119's passing and was unaware of full code status |
| Staff F | Unit Manager | Confirmed code status discrepancies and provider communication issues |
| Staff G | Registered Nurse | Observed infection control breaches and catheter care issues |
| Staff I | Licensed Practical Nurse | Confirmed advance directive findings and medication storage issues |
| Staff J | Social Services | Confirmed PASARR screening deficiencies |
| Staff D | Administrator | Confirmed PASARR screening deficiencies |
Inspection Report
Routine
Census: 86
Deficiencies: 3
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage, food safety, and infection prevention standards at Bedford Nursing & Rehabilitation Center.
Findings
The facility was found to have expired medication in use, improper food storage and handling practices in the kitchen, and failure to employ a fully trained infection preventionist for the resident census.
Deficiencies (3)
Expired medications were not removed from a medication cart.
Food and dishware were stored in violation of professional food safety standards, including spoiled vegetables and improperly dried cups.
The facility failed to employ an infection preventionist who completed specialized training in infection prevention and control.
Report Facts
Residents census: 86
Medication carts observed: 3
Kitchen observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse | Confirmed expired medication was in use |
| Staff H | Food Service Director | Confirmed food safety violations and dishware storage practices |
| Staff D | Infection Preventionist | Responsible for infection prevention program but had not completed specialized training |
| Staff A | Director of Nursing | Provided information about Staff D's role as Infection Preventionist |
| Staff E | Registered Nurse | Assisted with infection control program but had not completed specialized education |
Inspection Report
Deficiencies: 1
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with hospice service coordination and communication requirements for residents receiving hospice care.
Findings
The facility failed to implement an effective communication process to ensure hospice recommendations were addressed for one resident receiving hospice services, resulting in a delay in adjusting medication orders as recommended by hospice.
Deficiencies (1)
Failure to secure a communication process ensuring hospice recommendations were addressed for Resident #228, leading to a delay in implementing increased methadone dosage.
Report Facts
Residents affected: 1
Dates of hospice service: Resident #228 received hospice services from 10/7/23 to 12/1/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Nurse Unit Manager | Interviewed regarding communication of hospice recommendations on 10/19/23 |
| Staff K | Medical Director | Attending physician for Resident #228; interviewed about hospice recommendations |
| Staff J | Regional Nurse | Confirmed findings regarding hospice communication |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident dignity, medication management, professional standards of care, medication storage, food safety, and hospice services at Bedford Nursing & Rehabilitation Center.
Findings
The facility was found deficient in maintaining resident dignity during dressing changes, notifying physicians of unavailable medications, following physician orders for skin conditions, securing and labeling medications properly, maintaining cleanliness in the kitchen dishwashing area, and ensuring effective communication for hospice services. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (6)
Failed to ensure dignity was maintained for 1 of 1 residents reviewed for dressing changes; door and curtain remained open during dressing change.
Failed to notify resident's physician when medications were unavailable for 1 resident; missed doses of Clobazam without documented notification.
Failed to follow physician's orders for skin condition treatment for 1 resident; observed dressing did not comply with orders.
Failed to ensure medications were secured for 2 of 3 medication carts and failed to label medications with open expiration dates for 1 of 3 medication carts and 1 medication room.
Failed to maintain a clean environment in the kitchen dishwashing area; fans and ceiling vent had accumulated dust and grease.
Failed to secure a communication process ensuring hospice service needs were addressed for 1 resident; hospice recommendations not properly communicated or documented.
Report Facts
Residents reviewed: 18
Medication carts observed: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Unit Manager | Staff B involved in dressing change observation and interview confirming dignity deficiency; also involved in hospice communication interview | |
| Director of Nursing | Staff D interviewed regarding medication notification deficiency | |
| Nurse Unit Manager | Staff G interviewed regarding medication cart security | |
| Medication Nursing Assistant (MNA) | Staff H and Staff I interviewed regarding medication cart labeling and security | |
| Regional Nurse | Staff J interviewed regarding medication room labeling and hospice communication | |
| Dietary Director | Staff L interviewed regarding kitchen cleanliness deficiency | |
| Medical Director | Staff K attending physician for Resident #228, interviewed regarding hospice communication |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as an annual survey of Bedford Nursing & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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