F 0811
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services
as per their plan of care, and feeding assistants are trained and supervised.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure staff had successfully completed a
State-approved training course for feeding assistance before feeding residents who required staff to feed
them, for 1 of 1 residents (Resident #1) reviewed for meal assistance.
The facility did not ensure the Social Worker completed a state approved training course for feeding
residents before assisting Resident #1 with feeding.
This failure could place residents who required assistance with eating at risk of aspiration and choking.
Findings included:
Record review of Resident #1's admission record, dated 03/20/2025, revealed an [AGE] year-old female
who admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (A
neurodegenerative disease primarily affecting the central nervous system affecting both motor and
non-motor systems), generalized anxiety disorder, and essential tremor (a neurological condition causing
involuntary, rhythmic shaking).
Record review of Resident #1's admission MDS assessment, dated 02/13/2025, revealed a BIMS score of
12, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 required
supervision with eating.
Observation on 03/20/2025 at 1:51 pm, revealed Resident #1 lying in bed. The Social Worker was standing
up next to Resident #1's bed, wearing gloves and feeding Resident #1 a tuna sandwich. The Social Worker
would bring up the sandwich to Resident #1's mouth and she would take a bite. Resident #1 was observed
holding another sandwich with her left hand but was not able to bring her hand up to her mouth.
Interview on 03/20/2025 at 2:00 pm, the Social Worker stated his duties included to walk around and see
who needed help and he would assist residents with meals if the situation came up. He stated he could not
say for sure if he was trained to assist residents with feeding. He stated he wore gloves for health concerns
and some residents preferred that they wore gloves. He stated there could be a dignity issue when standing
over residents while feeding. The Social Worker stated CNAs usually assisted residents with meals, and he
did not assist any other residents with feeding today.
Interview on 03/26/2025 at 11:31 am, the Administrator stated CNAs and nurses were trained how to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455798
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455798
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bedford Wellness & Rehabilitation
2001 Forest Ridge Dr
Bedford, TX 76021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0811
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
feed as part of their competency. He stated they did general in-services on customer service but no training
on how to feed residents. He stated Resident #1 was able to feed herself, and the Social Worker was
assisting. He stated all of the department heads had been checked off on checking trays, puree and
mechanical diets. The Administrator stated the Social Worker was setting up and not feeding Resident #1.
The Administrator stated when the SW brought the food to Resident #1's mouth, it was not considered
feeding and the SW was setting up. He stated the risk was an employee not knowing if something was not
right with the patient while feeding but it did not apply in this case. Surveyor requested feeding and/or paid
feeding assistant policy.
Interview on 03/26/2025 at 2:19 pm, the DON stated Resident #1 was normally independent, able to feed
herself and the managers could set up the tray for her. She stated the risk if staff were not trained could be
choking or giving the wrong diet, but she stated she did not think the SW was feeding Resident #1. The
DON stated there was no policy on assisted feeding and normally the skills were taught at school so the
CNAs and Nurses were trained already.
Record review of the Social Worker's file and training record revealed no state approved feeding training
course was taken.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455798
If continuation sheet
Page 2 of 2
