Facility Watch Inspection records for every certified US nursing home

Bedford Post Acute

136 Donahoe Manor Road
Bedford, PA 15522
(814) 623-9075

CCN
395221
Certified beds
72
Ownership
For profit - Corporation
Chain
Pacs Group

Nurse staffing

3.28
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.90 hours per resident per day

Nursing staff turnover: 48% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected November 12, 2025

1 citation · from a complaint investigation · Health
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Deficient, Provider has date of correction · corrected December 12, 2025

Inspected September 3, 2025

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 30, 2025

Inspected July 2, 2025

9 citations · Health
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0688 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected August 5, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected August 5, 2025
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected August 5, 2025

Inspected April 7, 2025

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 8, 2025

Inspected August 1, 2024

15 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0623 No actual harm with potential for more than minimal harm · Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0661 No actual harm with potential for more than minimal harm · Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0730 No actual harm with potential for more than minimal harm · Isolated

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0849 No actual harm with potential for more than minimal harm · Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected September 23, 2024
D
F0947 No actual harm with potential for more than minimal harm · Isolated

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Deficient, Provider has date of correction · corrected September 23, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected September 23, 2024
E
F0867 No actual harm with potential for more than minimal harm · Pattern

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected September 23, 2024

Inspected March 27, 2024

2 citations · from a complaint investigation · Health
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Deficient, Provider has date of correction · corrected May 22, 2024
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected May 22, 2024

Inspected August 17, 2023

18 citations · Health
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0882 No actual harm with potential for more than minimal harm · Isolated

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Deficient, Provider has date of correction · corrected September 27, 2023
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0641 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0658 No actual harm with potential for more than minimal harm · Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0686 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0755 No actual harm with potential for more than minimal harm · Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0758 No actual harm with potential for more than minimal harm · Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0761 No actual harm with potential for more than minimal harm · Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected September 27, 2023
E
F0867 No actual harm with potential for more than minimal harm · Pattern

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Deficient, Provider has date of correction · corrected September 27, 2023

Inspected July 24, 2023

1 citation · from a complaint investigation · Health
E
F0760 No actual harm with potential for more than minimal harm · Pattern

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected August 31, 2023

Inspected July 6, 2023

6 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected August 22, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected August 22, 2023
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected August 22, 2023
E
F0561 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Deficient, Provider has date of correction · corrected August 22, 2023
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected August 22, 2023
E
F0836 No actual harm with potential for more than minimal harm · Pattern

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Deficient, Provider has date of correction · corrected August 22, 2023

Ownership transfers

EffectiveSellerBuyer
11/01/2024136 Donahoe Manor Road Operations LLCBedford SNF Healthcare LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.