Core Of Bedford

Based on interview and record review, the facility failed to ensure the appropriate discharge information was provided for 5 of 5 residents reviewed for hospitalization. Information was not communicated to the receiving health care institution or provider, Notice of Transfer and Discharge was not provided, bed hold policies were not provided. (Resident 4, Resident 6, Resident 8, Resident 17, Resident 36)Findings include: 1. On 3/16/26 at 11:23 a.m., Resident 6's clinical record was reviewed. The diagnosis included, but was not limited to COPD (chronic obstructive pulmonary disorder). On 1/15/26 at 3:25 a.m., a progress note indicated the resident was sent and admitted to the hospital. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. 2. On 3/16/26 at 12:03 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a clean, homelike environment in 3 of 4 resident shower/bathrooms used by 34 of 34 residents, and for 2 of 12 resident rooms reviewed for environmental concerns (Northeast Bathroom, Southwest Bathroom, Southeast Bathroom, room [ROOM NUMBER], room [ROOM NUMBER])Findings include:1. On 3/17/26 at 10:20 a.m. and 2:00 p.m., on 3/18/26 at 10:05 a.m. and 2:50 p.m., and on 3/19/26 at 11:20 a.m., gnats were observed flying around in the northeast resident bathroom. 2. On 3/17/26 at 9:50 a.m. and on 3/18/26 at 3:05 p.m., and black and brown substance was observed around the base of the toilet in the southwest resident bathroom. 3. On 3/17/26 at 9:55 a.m. and on 3/18/26 at 3:10 p.m., a gray fuzzy substance was observed on and in the ceiling vent, a black substance was observed around the base of the toilet, and the toilet was observed to be anchored at an angle towards the wall in the southeast resident bathroom. 4. On 3/16/26 at 11:16 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms. This was observed in 3 of 18 resident rooms in the facility (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]).Findings include: A review of the facility's Rooms Size Certification, received from the Administrator on 3/16/26 at 11:00 a.m., indicated the following:The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft. 76.59 sq. ft. per resident, SNF/NF.room [ROOM NUMBER]: 2 beds 157.98 sq. ft. 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft. 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], 6, and 8, rooms with the variances, were observed on 3/16/26. The rooms were observed to have the following number of beds:room [ROOM NUMBER] - 2 bedsroom [ROOM NUMBER] - 2 bedsroom [ROOM NUMBER] - 2 bedsDuring an interview on 3/16/26 at 11:00 a.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility 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) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. A review of Resident B's weights indicated the following: - On 1/2/25, the resident weighed 156.8 pounds. - On 1/17/25, the resident weighed 157.1 pounds. - On 1/23/25, the resident weighed 144.2 pounds. - On 1/30/25, the resident weighed 146.2 pounds. - On 2/11/25, the resident weighed 137.4 pounds. - On 2/19/25, the resident weighed 127.9 pounds. There was an assessed significant weight loss of 18.59% from 1/17/25 to 2/19/25. The resident's progress notes indicated the following: - A Nutrition/Dietary note from 2/17/25 at 12:30 p.m., indicated Resident B had a significant change of 19.4 pounds and 12.4% weight loss over 30 days. The clinical record for Resident B lacked documentation of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. The resident's nursing progress notes indicated the following: - On 2/8/25 at 1:47 p.m., new orders for X-ray of right ribs, right femur, right hip, total views of all X-rays. - On 2/8/25 at 2:45 p.m., follow-up day 2 of 3 awaiting X-rays of right ribs, right femur and right hip due to complaints of pain with movement. - On 2/9/25 at 7:20 a.m., nurse was notified by CNA's that resident was unable to straighten right leg, while assessing resident it was noted pain and discomfort while attempting to change and reposition resident. He was noted to have a recent fall on 2/6/25 and orders were obtained 2/8/25 for X-rays. - On 2/9/25 at 8:05 a.m., hospital ambulance arrived to transport resident to emergency room for evaluation and treatment. - On 2/9/25 at 11:15 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations. Findings include: During an initial kitchen tour on 2/17/25 at 10:45 a.m., a large container containing opened bags of rice was observed without a lid in the dry storage area. During a follow-up visit on 2/20/25 at 12:01 p.m., the same rice container was observed uncovered in the dry storage area. During an interview at that time, the Dietary Manager indicated the container should have a lid since there were opened bags of rice in it. On 2/20/25 at 12:40 p.m., the Administrator provided a copy of the facility policy, Storage of Dry Food and Supplies, undated, and indicated it was the policy currently being used. A review of the policy indicated, . Use seamless or plastic containers with tight-fitting covers to store products . On 2/21/25 at 10:45 a.m., the Indiana State Department of Health, RETAIL FOOD ESTABLISHMENT SANITATION REQUIREMENTS. TITLE 410 IAC 7-24, dated 11/13/04, was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives. (Resident 12) Finding includes: On [DATE] at 2:37 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and a history of transient ischemic attack (temporary blockage of blood flow to the brain, causing stroke like symptoms). The Advanced Directives, a choice of treatment document, dated [DATE], was signed by the Resident's POA (power of attorney), and indicated the resident was to be comfort measures only (No CPR to be performed). The Physician's Orders, dated [DATE], indicated resident had a current order for CPR (cardiopulmonary resuscitation). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR (do not resuscitate). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR. A Provider Note, dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment. (Resident 234) Finding includes: On 2/18/25 at 2:04 p.m., Resident 234's clinical record was reviewed. The diagnoses included, but not limited to, schizoaffective disorder (condition that combines symptoms of schizophrenia and a mood disorder) and dementia. Notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 2/15/23, indicated, Final Determination By: Determination Date: 2/15/23, Level II Outcome: Long Term Approval without Specialized Services. A Significant Change MDS (Minimum Data Set) assessment, dated 9/24/24, did not indicate the resident was a PASARR level II. During an interview with the MDS coordinator on 2/20/25 at 10:10 a.m., she indicated section A1500 on MDS assessment, dated 9/24/24, was marked no in error and indicated it should have been marked yes for PASARR Level II. She indicated they did not have a MDS assessment coding policy, they followed the Resident Assessment Instrument (RAI)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care. (Resident 1) Findings include: On 2/18/25 at 2:40 p.m., Resident 1 was observed sitting in his wheelchair outside his room with oxygen being administered via nasal cannula (N/C) at 4L (liters). There was no date observed on the N/C tubing. On 2/19/25 at 9:55 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/19/25 at 11:43 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 2:44 p.m., Resident 1 was observed sitting in his wheelchair inside his room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 10:42 a.m., Resident 1 was observed laying asleep in bed with oxygen being administered via N/C at 4L. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]). Findings include: Review of the facility's Rooms Size Certification, received from the Administrator on 2/17/25 at 12:50 p.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], were observed on 2/19/25 at 2:00 p.m The rooms were observed to have the following number of beds two beds in each room. During an interview on 2/19/25 at 2:10 p.m., the facility Administrator indicated room [ROOM NUMBER], room [ROOM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed for medication reconciliation. (Resident B) Findings include: During an interview on 1/17/25 at 9:45 a.m., the Administrator (ADM) indicated she was notified regarding missing pills for Resident B. The ADM's investigation singled out two nurses, the Director of Nursing (DON) and LPN 1, during the time the pills went missing. The facility never found the missing pills. On 1/17/24 at 9:50 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, malignant neoplasm of the breast, history of malignant neoplasm of the brain, and low back pain. An 11/7/24 physician's order indicated the resident was ordered oxycodone (a controlled substance medication used to treat moderate to severe pain) 7.5-325 milligrams every 6 hours, as needed for pain. A review of the drug disposal form did not indicate the resident's oxycodone was disposed. A review of the controlled substance inventory count sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were observed on 4/23/24 at 11:00 a.m. The rooms were observed to have the following number of beds: room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds A review of the facility's Rooms Size Certification, received from the Administrator on 4/26/24 at 11:00 a.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER] - 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. During an interview on 4/26/24 at 11:15 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.