Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Core Of Bedford during CMS and state inspections, most recent first.
Missing transfer, discharge, and bed-hold documentation: The facility lacked documentation for 5 residents who were transferred or sent to the hospital/ER. Records did not show that a written Notice of Transfer and Discharge or the bed-hold policy was provided to the resident and resident representative, and they also did not show that required transfer information was sent to the receiving provider. The affected residents included individuals with COPD, stroke, dementia, osteomyelitis, paraplegia, cellulitis, hemiplegia, a gastrostomy tube, and UTI.
Surveyors found multiple environmental cleanliness issues in resident bathrooms and rooms, including gnats in bathrooms and resident rooms, black and brown residue around toilets, a gray fuzzy substance in a ceiling vent, a toilet installed at an angle, and a floor-based HVAC unit missing its base cover with exposed interior residue. In one room, peeling wallpaper exposed a brown substance on the wall. The Administrator acknowledged the concerns were in need of correction, and the facility’s resident rights stated that residents must be provided a safe, clean, comfortable, and homelike environment.
A facility failed to provide at least 80 sq. ft. per resident in 3 multiple-occupancy rooms. A review of the room size certification showed each of the 3 double-occupancy rooms measured less than 80 sq. ft. per resident, and observation confirmed 2 beds in each room. The Administrator stated the rooms had variance waivers and were licensed for double occupancy.
A resident with a history of stroke and dysphagia experienced a dislodged gastrostomy tube after staff failed to consistently verify and document tube placement as required by facility policy. The resident developed leakage, pain, and ultimately aspiration pneumonia and sepsis, resulting in hospitalization and the inability to replace the G-tube for several weeks.
A facility failed to notify a resident's representative of a significant weight loss in a resident with dementia. The resident experienced an 18.59% weight loss over a month, but there was no documentation of notification to the representative. The MDS Coordinator confirmed the oversight, which violated the facility's policy requiring immediate notification of care changes.
A resident with dementia experienced a fall that was not documented in their clinical record. Despite the resident's complaints of pain and subsequent X-rays ordered on 2/8, the fall on 2/6 was not recorded. Interviews revealed that staff were unaware of the fall, and the facility's policy requiring incident documentation was not followed.
The facility failed to store food properly, as observed during two kitchen inspections. A container with opened bags of rice was found without a lid, contrary to the facility's policy and state sanitation requirements. The Dietary Manager confirmed the need for a lid to prevent contamination.
A facility failed to accurately document a resident's code status, resulting in a discrepancy between the advanced directive and physician's orders. The resident's advanced directive, signed by their POA, indicated comfort measures only, but the physician's orders stated CPR. Interviews with the Administrator and DON revealed no documentation for changing the directive from DNR to CPR, leading to potential initiation of CPR against the resident's wishes.
A facility failed to accurately assess a resident with schizoaffective disorder and dementia, as their MDS assessment did not reflect the correct PASARR Level II status. The MDS coordinator admitted the error and noted the absence of a specific MDS assessment coding policy, relying instead on the RAI manual.
A facility failed to label oxygen tubing with the date for a resident receiving respiratory care. The resident, with hemiplegia and traumatic brain injury, was observed multiple times receiving oxygen via nasal cannula without a date on the tubing. The MDS Coordinator noted that the tubing was changed weekly, but there was no physician order for this, and the longer tubing provided by hospice was not dated. The facility's policy did not require dating the tubing.
The facility did not meet the required minimum of 80 square feet per resident in three multiple occupancy rooms, with each room having less than the required space per resident. The Administrator noted that these rooms had room variance waivers and were licensed for double occupancy.
A facility failed to accurately reconcile and document the disposition of controlled substances for a resident prescribed oxycodone. Missing pills were reported, and an investigation revealed discrepancies in the inventory count sheet and lack of required signatures for medication removal and disposal. The facility's policy requires two licensed nurses to witness and document the destruction of controlled medications, which was not followed.
The facility failed to provide at least 80 square feet per resident in three multiple occupancy rooms, each containing two beds but measuring less than the required space per resident. The Administrator confirmed these rooms had variance waivers and were licensed for double occupancy.
Missing transfer, discharge, and bed-hold documentation
Penalty
Summary
The facility failed to ensure appropriate discharge information was provided for 5 of 5 residents reviewed for hospitalization. For each of the five residents, the clinical record lacked documentation that a written Notice of Transfer and Discharge was provided to the resident and resident representative, lacked documentation that the bed-hold policy was provided to the resident and/or resident representative, and lacked documentation that required information was conveyed to the receiving health care institution or provider upon transfer. Resident 6 had COPD and was sent and admitted to the hospital after a progress note documented the transfer. Resident 8 had cerebral infarction and was sent and admitted to the hospital after a progress note documented the transfer. Resident 17 had dementia and was sent and admitted to the hospital, but the record did not contain the required transfer and discharge documentation. Resident 4 had osteomyelitis, paraplegia, and cellulitis and was transferred to the emergency room and later returned to the facility. Resident 36 had hemiplegia, a gastrostomy tube, and a UTI and was transferred to the emergency room and later returned to the facility. During interview, the Administrator and MDS Coordinator stated the facility did not have documentation showing that the written notice, bed-hold policy, or required transfer information had been provided for the five residents reviewed.
Unclean and poorly maintained resident bathrooms and rooms
Penalty
Summary
The facility failed to ensure a clean, homelike environment in 3 of 4 resident shower/bathrooms used by 34 of 34 residents and in 2 of 12 resident rooms reviewed for environmental concerns. Surveyors observed gnats flying around in the northeast resident bathroom on multiple observations, black and brown substance around the base of the toilet in the southwest resident bathroom, and a gray fuzzy substance on and in the ceiling vent in the southeast resident bathroom. In the southeast bathroom, a black substance was also observed around the base of the toilet, and the toilet was anchored at an angle toward the wall. In two resident rooms, gnats were observed flying around residents' beds and sink on multiple occasions. In one room, the old floor-based heating/air conditioning unit was missing the base cover, exposing a black substance on the interior surface, and the wallpaper on the south wall was peeling off, exposing a brown substance beneath it. During interview, the Administrator indicated the environmental concerns existed and were in need of correction. The facility's resident rights document stated that the facility must provide a safe, clean, comfortable, and homelike environment.
Insufficient square footage in multiple resident rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms. A review of the facility's Rooms Size Certification, received from the Administrator on 3/16/26 at 11:00 a.m., showed that room [ROOM NUMBER] measured 153.19 sq. ft. for 2 beds, or 76.59 sq. ft. per resident; room [ROOM NUMBER] measured 157.98 sq. ft. for 2 beds, or 78.99 sq. ft. per resident; and room [ROOM NUMBER] measured 152.97 sq. ft. for 2 beds, or 76.48 sq. ft. per resident. These 3 rooms were observed on 3/16/26 and each had 2 beds in the room. During interview, the Administrator stated that rooms [ROOM NUMBER] had variance waivers and were licensed for double occupancy with two beds in each room.
Failure to Ensure Proper G-Tube Care and Placement Verification
Penalty
Summary
A resident with a history of stroke, hemiplegia, dysphagia, and MRSA infection was admitted with a recently placed gastrostomy tube (G-tube) for enteral feeding. The care plan and baseline care plan indicated the need for continuous feeding via G-tube and required verification of tube placement prior to medication administration and per facility protocol. However, documentation confirming the placement of the feeding tube was missing for several days prior to the resident's hospitalization. On multiple occasions, the resident was observed to have issues with the G-tube, including leakage around the insertion site, pain, and grimacing during care. Despite these symptoms, there was no documented evidence that staff verified the tube's placement as required by facility policy. Interviews with staff confirmed that placement checks should have been performed and documented, but the Medication Administration Record and Treatment Administration Record lacked this documentation for the relevant dates. It was also noted that the nurse responsible for care on the days in question had not signed the facility's G-tube training and policy in-service. The resident ultimately experienced a dislodged G-tube, leading to aspiration pneumonia, sepsis, and the need for hospitalization. Hospital records indicated that the G-tube had become malpositioned, resulting in feeding into the chest wall and abdomen, and the resident could not have a new G-tube placed for approximately six weeks due to infection. The facility's failure to ensure necessary interventions and proper documentation contributed to the resident's adverse outcome.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's representative of a significant weight loss, which was identified in one of the three residents reviewed for notification of change. The resident, referred to as Resident B, had a diagnosis that included dementia with behavior disturbance. A review of Resident B's weight records showed a significant weight loss from 157.1 pounds on January 17 to 127.9 pounds on February 19, amounting to an 18.59% decrease. Despite this significant change, there was no documentation indicating that the resident's representative had been informed of the weight loss. During an interview, the Minimum Data Set Coordinator acknowledged that the resident's representative should have been notified about the weight loss but was not. The facility's policy, dated July 2009, mandates immediate notification of the resident's legal representative when there are changes to the resident's care. This deficiency was related to a specific complaint, IN00454567, and was documented under citation 3.1-5(a)(2).
Failure to Document Resident Fall
Penalty
Summary
The facility failed to document a fall for Resident B, who was one of the three residents reviewed for accidents. Resident B, diagnosed with dementia with behavior disturbance, experienced a fall on 2/6/25, which was not documented in the clinical record. The nursing progress notes indicated that on 2/8/25, new orders were made for X-rays of the right ribs, right femur, and right hip due to complaints of pain with movement. On 2/9/25, the resident was unable to straighten the right leg, and a nurse was notified by CNAs about the resident's pain and discomfort during repositioning. The resident was then transported to the emergency room for evaluation and treatment and returned to the facility with a diagnosis of a right hip contusion. Interviews conducted on 3/6/25 revealed that the Minimum Data Set Coordinator was unaware of the fall on 2/6/25, indicating that the last documented fall was on 2/2/25. RN 1 confirmed that Resident B had a fall during the night shift on 2/6/25 and was the nurse who ordered the X-rays due to the resident's pain. The facility's policy, Procedure for Falls, which was undated, required that incidents be charted in the nurse's notes, but this was not adhered to in the case of Resident B's fall on 2/6/25.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety during two separate kitchen observations. On an initial kitchen tour, a large container with opened bags of rice was found without a lid in the dry storage area. During a follow-up visit, the same container remained uncovered. The Dietary Manager acknowledged that the container should have a lid due to the opened bags of rice. The facility's policy, 'Storage of Dry Food and Supplies,' requires the use of seamless or plastic containers with tight-fitting covers for storing products. Additionally, the Indiana State Department of Health's Retail Food Establishment Sanitation Requirements mandate that food be protected from contamination by storing it in covered containers or wrappings.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to accurately document a resident's choice of code status, leading to a discrepancy between the resident's advanced directive and the physician's orders. The resident, who had a history of Alzheimer's disease and transient ischemic attack, had an advanced directive signed by their power of attorney indicating a preference for comfort measures only, with no CPR to be performed. However, the physician's orders indicated that the resident had a current order for CPR, contradicting the advanced directive. Interviews with the facility's Administrator and Director of Nursing revealed uncertainty and lack of documentation regarding any request to change the resident's advanced directive from DNR to CPR. Despite the advanced directive indicating DNR, the staff would have initiated CPR based on the current order, which was inconsistent with the resident's documented wishes. The facility's choice of treatment policy, although undated, emphasized respecting the resident's wishes for death with dignity, yet this was not reflected in the actions taken.
Inaccurate Assessment of PASARR Level II Status
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident diagnosed with schizoaffective disorder and dementia. A review of the resident's clinical record revealed a PASARR Level II Outcome dated February 15, 2023, which indicated long-term approval without specialized services. However, a Significant Change MDS assessment dated September 24, 2024, did not reflect the resident's PASARR Level II status. During an interview, the MDS coordinator acknowledged that section A1500 of the MDS assessment was incorrectly marked as 'no' instead of 'yes' for PASARR Level II. The coordinator admitted that the facility did not have a specific MDS assessment coding policy and relied on the Resident Assessment Instrument (RAI) manual for guidance.
Failure to Label Oxygen Tubing with Date
Penalty
Summary
The facility failed to ensure that oxygen tubing was labeled with the date for a resident receiving respiratory care. The resident, who had diagnoses including hemiplegia and traumatic brain injury, was observed multiple times over several days receiving oxygen via nasal cannula at 4 liters per minute without any date marked on the tubing. This lack of labeling was consistent across different settings, including outside the resident's room, in the dining room, and while the resident was asleep in bed. Interviews with the MDS Coordinator revealed that the facility's practice was to change the tubing every Sunday, but there was no specific physician order for this practice. Additionally, the MDS Coordinator noted that the resident preferred longer tubing, which was provided by hospice and not marked with a date. The facility's policy on oxygen concentrators did not include a requirement to date the oxygen tubing, contributing to the oversight.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for three of the 18 resident rooms surveyed. Specifically, room numbers [ROOM NUMBER], [ROOM NUMBER], and [ROOM NUMBER] were found to have less than the required space per resident, with measurements of 76.59, 78.99, and 76.48 square feet per resident, respectively. These rooms were observed to have two beds each, and during an interview, the facility Administrator indicated that these rooms had room variance waivers and were licensed for double occupancy.
Failure in Controlled Substance Reconciliation and Documentation
Penalty
Summary
The facility failed to ensure accurate reconciliation and disposition of controlled substances for a resident, identified as Resident B, who was prescribed oxycodone for pain management. During an interview, the Administrator was informed of missing pills for Resident B, and an investigation pointed to two nurses, the Director of Nursing (DON) and an LPN, as being involved during the time the pills went missing. The facility was unable to locate the missing pills. A review of Resident B's clinical record showed a physician's order for oxycodone, but the drug disposal form did not indicate that the medication was disposed of properly. Further investigation revealed discrepancies in the controlled substance inventory count sheet, where a card was removed without the required signatures of two licensed nurses for verification. The DON conducted an audit and found a discrepancy between the pill count and the inventory sheet, with no initials to identify who removed the medication. The DON was informed by the LPN that the medication was destroyed, but the required documentation and signatures were missing. The facility's policy on medication disposal mandates that controlled medications be destroyed in the presence of two licensed nurses, with proper documentation, which was not adhered to in this case.
Failure to Provide Minimum Square Footage per Resident in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for three of the 18 resident rooms. Specifically, rooms [ROOM NUMBER], [ROOM NUMBER], and [ROOM NUMBER] were observed to have two beds each, but the floor areas measured 153.19 sq. ft., 157.98 sq. ft., and 152.97 sq. ft., respectively, resulting in less than the required 80 sq. ft. per resident. The Administrator confirmed that these rooms had room variance waivers and were licensed for double occupancy, but they did not meet the minimum space requirement per resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Bedford | 1.9 mi | ★★★★★ | 10 | 0 |
| Westview Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 3 | 0 |
| Stonebridge Health Campus | 2.7 mi | ★★★★★ | 4 | 0 |
| White River Lodge | 3.2 mi | ★★★★★ | 15 | 0 |
| Mitchell Manor | 10.3 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.