Nursing homes › Pennsylvania › Bedford Post Acute
136 Donahoe Manor Road, Bedford, PA 15522 · 8146239075 · 72 certified beds
Per CMS filings, this facility is affiliated with Pacs Group, a group operating 281 facilities in 16 states. Group record: average rating 2.8/5, 26 abuse citation icons, 13 facilities on the Special Focus list, $8,841,332 in federal fines. This facility rates below its group average (2.8/5).
Total nurse staffing: 3.53 (Pennsylvania median: 3.63). RN hours: 1.00. Weekend total: 3.19. Nursing staff turnover: 36%.
All-time on record: 54 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2025-11-12 | 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. | D | complaint | corrected 2025-12-12 |
| 2025-09-03 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-09-30 |
| 2025-07-02 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Health | corrected 2025-08-05 |
| 2025-07-02 | Keep residents' personal and medical records private and confidential. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | 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. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2025-08-05 |
| 2025-07-02 | 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. | D | Health | corrected 2025-08-05 |
| 2025-04-07 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2025-05-08 |
| 2024-08-01 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2024-09-23 |
| 2024-08-01 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | Health | corrected 2024-09-23 |
| 2024-08-01 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Ensure each resident receives an accurate assessment. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2024-09-23 |
| 2024-08-01 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Observe each nurse aide's job performance and give regular training. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | 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. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | 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. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Provide and implement an infection prevention and control program. | D | Health | corrected 2024-09-23 |
| 2024-08-01 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D | Health | corrected 2024-09-23 |
| 2024-03-27 | 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. | D | complaint | corrected 2024-05-22 |
| 2024-03-27 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | complaint | corrected 2024-05-22 |
| 2023-08-17 | 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. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Ensure each resident receives an accurate assessment. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | 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. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | 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. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | Health | corrected 2023-09-27 |
| 2023-08-17 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Health | corrected 2023-09-27 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| APT, FREDERICK | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/01/2024 |
| JERGENSEN, JOSHUA | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/01/2024 |
| MITCHELL, JOHN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/01/2024 |
| APT, FREDERICK | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/01/2024 |
| FISHER, MARIA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/01/2024 |
| JERGENSEN, JOSHUA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/01/2024 |
| MITCHELL, JOHN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 11/01/2024 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 395221. Corrections: data@carerecords.org.