Inspection Reports for Core of Bedford
514 16th St, Bedford, IN 47421, IN, 47421
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 23, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving Life Safety Code compliance, emergency preparedness testing, documentation accuracy, and resident care issues such as notification and assessment. Several complaint investigations were substantiated, including failures in medication reconciliation and resident notification, while most complaints were found unsubstantiated or corrected upon revisit. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance following previous citations and corrective actions.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to the care and management of a resident's gastrostomy tube (feeding tube) to ensure proper interventions were in place to prevent dislodgement and related complications.
Complaint Details
This citation relates to Intake 2646692. The complaint involved failure to confirm feeding tube placement on multiple dates and inadequate care leading to dislodgement and serious medical complications.
Findings
The facility failed to ensure appropriate care for a resident with a gastrostomy tube, resulting in dislodgement, hospitalization, sepsis, and inability to place a new G-tube for six weeks. Documentation of feeding tube placement verification was lacking on several dates prior to the incident.
Deficiencies (1)
Failed to ensure a resident received necessary interventions to prevent dislodgement of a gastrostomy tube, resulting in hospitalization and sepsis.
Report Facts
G-tube size: 20
Vancomycin dosage: 750
Amoxicillin-Pot Clavulanate dosage: 875
Amoxicillin-Pot Clavulanate dosage: 125
Sepsis treatment duration: 14
Timeframe for new G-tube placement: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed regarding care and assessment of Resident B and verification of G-tube placement |
| LPN 2 | Licensed Practical Nurse | Identified as nurse working on 9/27/25, 9/28/25, and 10/1/25 responsible for Resident B's care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care provided to Resident B and documentation of G-tube placement verification |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460911.
Complaint Details
Complaint IN00460911 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 33
Other Payor Residents: 1
Inspection Report
Re-Inspection
Census: 32
Capacity: 37
Deficiencies: 0
Date: May 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/17/2025 was performed to verify compliance with previous deficiencies.
Findings
At this PSR survey, Core of Bedford was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for one detached shed used for storage.
Report Facts
Facility capacity: 37
Census: 32
Inspection Report
Re-Inspection
Census: 28
Capacity: 28
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed February 20, 2025, and was conducted in conjunction with a PSR to the Investigation of Complaint IN00454567 completed on March 6, 2025.
Complaint Details
Complaint IN00454567 was investigated and corrected as of this visit.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey. Complaint IN00454567 was corrected. A continuing annual waiver was approved for the requirement of at least 100 square feet in single resident rooms.
Deficiencies (1)
Bedrooms measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; this requirement is not met as evidenced by a continuing annual waiver approved.
Report Facts
Census SNF/NF: 28
Total Capacity: 28
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 8
Inspection Report
Re-Inspection
Census: 28
Capacity: 28
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00454567 completed on March 6, 2025, conducted in conjunction with a PSR to the Recertification and State Licensure Survey completed February 20, 2025.
Complaint Details
Complaint IN00454567 was investigated and found to be corrected as of this visit.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00454567. The complaint was corrected.
Report Facts
Census SNF/NF: 28
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 8
Inspection Report
Annual Inspection
Census: 28
Capacity: 37
Deficiencies: 3
Date: Mar 17, 2025
Visit Reason
An Emergency Preparedness Recertification, Life Safety Code Recertification, and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and state licensure regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to conduct annual 90-minute testing of battery backup emergency lighting, combustible decorations on a resident room corridor door exceeding allowed limits, and improper use of extension cords and power strips as substitutes for fixed wiring in patient care areas.
Deficiencies (3)
Failed to ensure 1 of 1 battery backup light was tested annually for 90 minutes and maintain written records of visual inspections and tests.
Failed to ensure 1 of 18 resident room corridor doors was maintained without combustible decorations exceeding allowed limits.
Failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring within patient care vicinity.
Report Facts
Certified beds: 37
Census: 28
Resident room corridor doors: 18
Percentage coverage: 90
Audit period: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Reviewed findings at exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454567, which involved federal and state deficiencies related to allegations concerning resident care and documentation.
Complaint Details
Complaint IN00454567 was substantiated with federal and state deficiencies cited at F580 and F842 related to failure to notify a resident's representative of significant weight loss and failure to document a fall.
Findings
The facility failed to notify a resident's representative of significant weight loss and failed to document a fall for the same resident. The resident involved was deceased, and systemic changes including staff in-service and quality assurance audits were planned to address these issues.
Deficiencies (2)
Failed to ensure a resident's representative was notified of an assessed significant weight loss for 1 of 3 residents reviewed.
Failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents.
Report Facts
Census: 30
Total Capacity: 30
Weight loss percentage: 18.59
Weight loss percentage: 12.4
Residents audited weekly: 5
Records monitored weekly: 10
Records monitored biweekly: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Signed the report and provided facility policies during the investigation |
| Minimum Data Set Coordinator (MDS) | Interviewed regarding Resident B's weight loss and fall history | |
| RN 1 | Registered Nurse | Interviewed and indicated knowledge of Resident B's fall and subsequent X-ray orders |
| Director of Nursing | Responsible for conducting quality assurance audits related to weight loss and fall documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify a resident's representative of significant weight loss and failure to document a fall for Resident B.
Complaint Details
This citation relates to Complaint IN00454567.
Findings
The facility failed to notify the resident's representative of a significant weight loss of 18.59% for Resident B and failed to document a fall that occurred on 2/6/25. The facility policies on family notification and fall documentation were reviewed and found to be in place but not followed.
Deficiencies (2)
Failed to ensure a resident's representative was notified of an assessed significant weight loss for 1 of 3 residents reviewed for notification of change (Resident B).
Failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents (Resident B).
Report Facts
Weight loss percentage: 18.59
Weight loss percentage: 12.4
Dates of weight measurements: Weights recorded on 1/2/25, 1/17/25, 1/23/25, 1/30/25, 2/11/25, 2/19/25 for Resident B
Fall date: Feb 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator (MDS) | Indicated resident's representative should have been notified of weight loss but was not; unaware of fall on 2/6/25 | |
| RN 1 | Registered Nurse | Indicated Resident B had a fall on 2/6/25 and was the nurse who ordered X-rays due to pain |
| Administrator | Provided facility policies on family notification and procedure for falls |
Inspection Report
Renewal
Census: 30
Capacity: 30
Deficiencies: 5
Date: Feb 20, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 17 to 20, 2025.
Findings
The facility was found deficient in several areas including inaccurate documentation of residents' advanced directives, inaccurate resident assessments, unlabeled oxygen tubing, improper food storage, and inadequate room size in multiple occupancy rooms. Plans of correction and systemic changes were implemented for each deficiency.
Deficiencies (5)
Failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives.
Failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment (PASARR Level II documentation).
Failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care.
Failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations.
Failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms (Rooms 3, 6, and 8).
Report Facts
Census: 30
Total Capacity: 30
Deficiencies cited: 5
Room size measurements: 76
Room size measurements: 78
Room size measurements: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Interviewed regarding advanced directive documentation and facility policies |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, assessments, respiratory care, food safety, and room size standards at the Core of Bedford nursing facility.
Findings
The facility was found deficient in accurately documenting a resident's advanced directive, ensuring accurate resident assessments, labeling oxygen tubing with dates, storing food properly in the kitchen, and providing adequate room size per resident in multiple occupancy rooms.
Deficiencies (5)
Failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives.
Failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment.
Failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care.
Failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations.
Failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility.
Report Facts
Beds per room: 2
Room size per resident: 76.59
Room size per resident: 78.99
Room size per resident: 76.48
Oxygen flow rate: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00448728 completed on January 17, 2025.
Complaint Details
Complaint IN00448728 was investigated and found to be corrected.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448728 regarding allegations related to medication reconciliation and controlled substances.
Complaint Details
Complaint IN00448728 was substantiated with federal/state deficiencies cited at F755 related to medication reconciliation and controlled substance management.
Findings
The facility failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed (Resident B). There was a discrepancy in the controlled substance inventory and missing pills that were not properly documented or disposed of according to policy.
Deficiencies (1)
Failed to ensure accurate reconciliation and disposition of controlled substances for Resident B.
Report Facts
Census: 30
Total Capacity: 30
Medicare Residents: 3
Medicaid Residents: 20
Other Residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan M Jordan | HFA | Facility representative signing the report |
| LPN 1 | Nurse identified during investigation related to medication discrepancy | |
| Director of Nursing | DON | Conducted audit and identified medication discrepancy |
| Administrator | ADM | Notified of missing pills and provided facility policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted due to a complaint regarding missing controlled substance medication (oxycodone) for Resident B, focusing on medication reconciliation and disposal procedures.
Complaint Details
This citation relates to Complaint IN00448728.
Findings
The facility failed to ensure accurate reconciliation and disposition of controlled substances for Resident B. There was a discrepancy in the controlled substance inventory count, missing signatures on disposal documentation, and the facility never found the missing pills. The Director of Nursing and an LPN were involved in the investigation.
Deficiencies (1)
Failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed for medication reconciliation (Resident B).
Report Facts
Deficiencies cited: 1
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in investigation and audit of medication discrepancy |
| LPN 1 | Licensed Practical Nurse | Informed DON about destruction of pills on 12/4/24 |
| Administrator | Administrator | Notified about missing pills and provided facility policy |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448194.
Complaint Details
Complaint IN00448194 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 31
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00436577 and IN00441957 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00436577 and Complaint IN00441957 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in Complaints IN00436577 and IN00441957 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B, including the COVID-19 Focused Infection Control Survey.
Report Facts
Census SNF/NF: 31
Total Capacity: 31
Medicare Census: 2
Medicaid Census: 24
Other Payor Census: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Follow-Up
Census: 30
Capacity: 37
Deficiencies: 0
Date: Aug 5, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Recertification and State Licensure Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/16/24.
Findings
At this PSR survey, Core of Bedford was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR Subpart 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for one detached shed used for storage.
Report Facts
Certified beds: 37
Census: 30
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435407.
Complaint Details
Complaint IN00435407 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 28, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey completed on April 26, 2024.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Census: 33
Capacity: 37
Deficiencies: 5
Date: May 16, 2024
Visit Reason
An Emergency Preparedness Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and life safety code standards.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, failed to conduct required fire drills with verification of alarm transmission, did not complete annual fire door inspections, lacked documentation of electrical receptacle testing, and missed weekly generator inspection records for several weeks.
Deficiencies (5)
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures.
Failed to ensure 1 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station.
Failed to ensure annual inspection and testing of at least one fire door assembly was completed.
Failed to ensure documentation of electrical outlet receptacle testing for all resident sleeping rooms was available.
Failed to ensure a written record of weekly inspections for the generator was maintained for 6 of 52 weeks.
Report Facts
Certified beds: 37
Census: 33
Fire drills reviewed: 12
Fire drills missing verification: 1
Weeks missing generator inspection records: 6
Inspection Report
Renewal
Census: 33
Capacity: 33
Deficiencies: 1
Date: Apr 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over April 23-26, 2024.
Findings
The facility failed to provide at least 80 square feet per resident in multiple occupancy rooms for 3 of 18 resident rooms (Rooms 3, 6, and 8). However, these rooms had variance waivers in place and were licensed for double occupancy with two beds each.
Deficiencies (1)
Facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms (Room 3, Room 6, Room 8).
Report Facts
Number of beds in Room 3: 2
Number of beds in Room 6: 2
Number of beds in Room 8: 2
Square feet per resident in Room 3: 76.59
Square feet per resident in Room 6: 78.99
Square feet per resident in Room 8: 76.48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Laboratory Director or Provider/Supplier Representative who signed the report |
Inspection Report
Deficiencies: 1
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with room size requirements, specifically to verify that multiple occupancy resident rooms provide at least 80 square feet per resident and single resident rooms provide 100 square feet per resident.
Findings
The facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms observed. The rooms measured between 76.48 and 78.99 square feet per resident, which is below the required minimum.
Deficiencies (1)
Failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms.
Report Facts
Number of resident rooms with deficient room size: 3
Number of beds in each deficient room: 2
Square feet per resident in deficient rooms: 76.48
Square feet per resident in deficient rooms: 78.99
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420844.
Complaint Details
Complaint IN00420844 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00420844 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF beds: 35
Census total residents: 35
Census Medicare residents: 1
Census Medicaid residents: 27
Census other payor residents: 7
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417679.
Complaint Details
Complaint IN00417679 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 35
Total Census: 35
Census Payor Type: 35
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413562, IN00413583, and IN00413303.
Complaint Details
Complaints IN00413562, IN00413583, and IN00413303 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the three complaints. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Report Facts
Census SNF/NF: 35
Census Payor Type Medicaid: 34
Census Payor Type Other: 1
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411307.
Complaint Details
Complaint IN00411307 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 33
Other Payor Residents: 1
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405009 and IN00407737.
Complaint Details
Complaint IN00405009 - No deficiencies were cited related to the allegations. Complaint IN00407737 - No deficiencies were cited related to the allegations.
Findings
No deficiencies were cited related to the allegations in both complaints. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 35
Census Payor Type Medicaid: 34
Census Payor Type Medicare: 0
Census Payor Type Other: 1
Inspection Report
Follow-Up
Census: 35
Capacity: 37
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Recertification and State Licensure Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/20/23.
Findings
At this PSR survey, Core of Bedford was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR Subpart 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).
Report Facts
Certified beds: 37
Census: 35
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 22, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on March 17, 2023.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 34
Capacity: 37
Deficiencies: 5
Date: Apr 20, 2023
Visit Reason
An Emergency Preparedness Recertification and State Licensure Survey and a Life Safety Code Recertification were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements due to missing documentation for monthly generator load testing for seven of the last 12 months. Additionally, battery-operated smoke detectors in resident rooms were over 10 years old and lacked complete preventative maintenance documentation. The kitchen range hood exhaust system was not properly maintained, and fire drills were not conducted at unexpected times. Weekly generator inspection records were incomplete.
Deficiencies (5)
Failed to implement emergency power system inspection, testing, and maintenance requirements; missing documentation for monthly generator load testing for seven of the last 12 months.
Battery-operated smoke alarms in resident rooms were more than 10 years old and not properly maintained or documented.
Failed to maintain kitchen range hood exhaust system in proper working order; fan was unhinged.
Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions.
Failed to maintain complete written records of weekly generator inspections for 7 of 52 weeks.
Report Facts
Certified beds: 37
Census: 34
Missing monthly generator load testing documentation: 7
Missing weekly generator inspection records: 7
Quarterly fire drills conducted near end of month: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Interviewed regarding generator load testing documentation and other findings |
| Maintenance Director | Interviewed regarding smoke detector maintenance and generator testing |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 17, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided at the facility.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with specific needs, inadequate positioning assistance, incomplete pressure ulcer care and wound assessments, failure to implement infection prevention measures including glove use and water management, and insufficient room size per resident in multiple occupancy rooms.
Deficiencies (5)
Failed to develop a comprehensive care plan for a resident with a colostomy.
Failed to provide positioning assistance to a resident with hemiplegia and hemiparesis.
Failed to provide appropriate pressure ulcer care and prevent new ulcers; wound care referral and weekly wound assessments were incomplete.
Failed to implement infection prevention and control measures; gloves were not worn during blood glucose testing and water management program was not implemented.
Failed to provide rooms with at least 80 square feet per resident in multiple occupancy rooms for 3 of 18 rooms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 34
Residents affected: 3
Room size per resident: 76
Room size per resident: 78
Room size per resident: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Observed not wearing gloves during blood glucose testing for Resident 4 |
| LPN 1 | Licensed Practical Nurse | Indicated Resident 6 frequently changed colostomy bag and sometimes required assistance |
| DON | Director of Nursing | Indicated no care plan for Resident 6's colostomy and lack of documentation for wound care and positioning |
| CNA 4 | Certified Nursing Assistant | Tried to position Resident 8 with a pillow to prevent scratches |
| MDS Coordinator | Minimum Data Set Coordinator | Indicated lack of clinical documentation for Resident 8's positioning and provided infection control policy |
| Administrator | Facility Administrator | Provided Water Management Binder and Rooms Size Certification |
Inspection Report
Renewal
Census: 34
Capacity: 34
Deficiencies: 5
Date: Mar 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 14 to 17, 2023.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with colostomies and positioning needs, inadequate pressure ulcer care and documentation, failure to implement infection control measures including a water management program and glove use during blood glucose checks, and failure to provide adequate room size per resident in multiple occupancy rooms.
Deficiencies (5)
Failed to develop a comprehensive care plan for a resident with a colostomy.
Failed to provide services to maintain highest practicable quality of care for a resident's positioning needs.
Failed to provide services for pressure ulcer care including wound care referral and weekly wound assessments.
Failed to implement infection control measures including water management program and glove use during blood glucose monitoring.
Failed to provide at least 80 square feet per resident in multiple occupancy rooms (Rooms 3, 6, and 8).
Report Facts
Census: 34
Total Capacity: 34
Residents with colostomy care deficiency: 2
Residents affected by positioning deficiency: 1
Residents affected by pressure ulcer deficiency: 1
Residents affected by infection control deficiency: 34
Rooms with inadequate square footage: 3
Room sizes (sq ft per resident): 76
Room size (sq ft per resident): 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan M Jordan | Director of Nursing | Interviewed regarding care plan deficiencies and quality assurance |
| RN 1 | Registered Nurse | Observed not wearing gloves during blood glucose check |
| Administrator | Provided water management binder and room size certification information | |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident colostomy care |
| CNA 4 | Certified Nursing Assistant | Interviewed about positioning assistance for resident |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Date: Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394076.
Complaint Details
Complaint IN00394076 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00394076 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 28
Other Residents: 6
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391779.
Complaint Details
Complaint IN00391779 - Unsubstantiated due to lack of evidence.
Findings
The complaint IN00391779 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type: 33
Census Payor Type Medicaid: 28
Census Payor Type Other: 5
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