Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BEDFORD POST ACUTE
BEDFORD, PA · 72 certified beds · Last Life Safety survey June 17, 2026
CMS Certification Number 395221 · first certified August 1968
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- New ownershipOwnership changed November 1, 2024 (change of ownership)from 136 DONAHOE MANOR ROAD OPERATIONS LLC
Position within PA
9 citations — more than 43% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 7 months from now. This facility’s last Life Safety survey was June 2026. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 9 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 9 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 9 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 1, 2024 | 6 |
| July 2, 2025 | 2 |
| June 17, 2026 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-06-17 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2025-07-02 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2024-08-01 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2024-08-01 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2025-07-02 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-08-01 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2024-08-01 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-08-01 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 1
- Emergency Preparedness Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 17, 2026 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 27, 2026) |
July 2, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 11, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 11, 2025) |
August 1, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 21, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 21, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 21, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (September 16, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.