Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 The Laurels Of Bedford during CMS and state inspections, most recent first.
Surveyors found that two shower rooms were not maintained according to infection control standards, including soiled linens and resident clothing left on the floor, unlabeled personal care items such as shampoo and combs with hair present, and an unused brief stored on a sink. In another shower room, surveyors observed a pile of hair on the shower floor, missing tiles that prevented surfaces from being fully cleanable, unlabeled shampoo and body cleanser bottles, and an uncovered toilet plunger resting on the floor beside the toilet. The DON confirmed that these conditions did not meet infection control practices and that resident items should be labeled and soiled linens kept off the floor.
Two residents with significant medical conditions and documented need for assistance with bathing did not consistently receive their scheduled twice-weekly showers or baths. One resident with dementia and multiple chronic conditions was scheduled for showers on specific days during day shift but, according to point of care task (PCT) records, often received only one shower per week over several weeks. Another cognitively intact resident with post-stroke paralysis and other comorbidities was scheduled for evening shift showers twice weekly, yet PCT documentation showed entire weeks with no showers or only one provided, with limited refusal documentation. Both residents reported they did not always receive twice-weekly bathing, and the DON confirmed the missed showers upon review of the records and could not explain the failures.
Water Management Program Lacked Active Legionella and OPPP Controls: The facility failed to maintain an active and ongoing water management program to reduce Legionella and other OPPP risk. A discolored water condition was observed in a tub room, the MD said the room was not regularly used, and flushing was only done for the hot water tank rather than specific fixtures. The MD also reported using an incorrect reagent with the digital colorimeter for free chlorine testing; when tested per manufacturer directions, the hot water from a sink measured .04 ppm. The Water Management Plan lacked an updated risk assessment and did not include a facility description of water flow and building design.
The facility failed to keep domestic hot water at safe temperatures, with the boiler room outgoing water measuring 133 F and shower fixtures in two shower rooms reaching 130 F and 130.8 F. The MD stated that routine temperature checks focused on resident room fixtures, that showers were not part of regular testing, and that fixtures were checked about once every two months.
Unsafe and Unsanitary Environmental Conditions: Multiple areas of the facility were observed with cleanliness and maintenance issues, including ajar kitchen exhaust filters, stained and discolored privacy and shower curtains, debris on rooftop air units, dirty linen storage and laundry carts, hair and debris in a shower room, a strong odor and yellowish puddle in another shower room, a broken tile with sharp edges and dust/dead insects on a windowsill, stained furniture in the dining area, and a mop sink faucet with hot water bleeding into the cold-water supply. Housekeeping Manger J stated privacy curtains are addressed about once a month or as needed.
Advance directive information was not accurately completed for a resident with CKD and intact cognition. The resident signed a DNR form, but it was not witnessed by two persons at the time of signing; one witness signed the next day, and an LPN could not explain the after-the-fact witness signature.
Inaccurate PASRR Coding on MDS Assessment: The facility failed to accurately code A1500 on a resident’s MDS. The resident had diagnoses including schizoaffective disorder and major depressive disorder, and the record included an OBRA Level II evaluation marked for mental illness with DSM diagnoses of schizoaffective disorder and unspecified neurocognitive disorder. The MDS Nurse coded A1500 as No, stating schizophrenia did not qualify as a serious mental illness and that they were looking for conditions such as epilepsy and developmental delay.
Failure to coordinate CMH Level II review for a resident with severe cognitive impairment and psychiatric diagnoses. The resident’s record noted an OBRA Level II Evaluation had been completed, but the actual evaluation was not in the chart, and SWs reported they had not yet reviewed it when asked. The Level II included treatment-planning recommendations such as therapy assessment for independent fluid use and further evaluation for a neurocognitive disorder.
A resident with severe cognitive impairment, bilateral upper extremity impairment, and hand contracture was care planned to wear bilateral palm protectors during the day as tolerated. The resident was observed twice without the palm protectors in place, including while seated in the dining room and while in bed. A CNA stated they were not aware of any orthotic devices and did not recall the palm protectors being listed on the Kardex, although the Kardex did direct their use.
Failure to Provide Effective Bowel Management: A resident with impaired cognition and mobility issues reported constipation for about a month and said the food made him constipated. The record showed several multi-day gaps without documented bowel movements, PRN laxatives ordered for constipation were rarely or never given, and there was no documentation of other constipation interventions. The DON stated the facility had no structured bowel management program or related policy.
A facility failed to report and investigate an incident where a resident with behavioral issues struck another resident on her recently operated arm, causing pain. The incident was not documented properly, and the investigation was incomplete, with no report to the state. The care plan for the aggressive resident was not updated following the incident, highlighting a lapse in protocol adherence.
A facility failed to investigate and document an incident where a resident with a recent fracture was reportedly hit by another resident with behavioral issues. The incident was not properly documented or reported to the state, and the care plan for the resident with behavioral issues was not updated to prevent future occurrences. This lack of thorough investigation and follow-up highlights the facility's inadequate response to the incident.
The facility's insufficient staffing in Dietary Services affected 107 residents, causing delays in meal preparation and delivery. Observations revealed that additional staff from another facility were assisting with meal services, and the Dietary Manager confirmed understaffing. Residents reported receiving meals significantly later than scheduled, with some meals arriving hours late. The facility occasionally ordered pizza from an outside vendor to compensate for the delays.
The facility failed to maintain cleanliness and proper sanitation in the food service area, affecting 107 residents. Observations revealed soiled kitchen flooring, inadequate dish machine sanitization, and improper food storage practices. Equipment such as the Juice Machine and ovens were found with food residue, and the ventilation grill was heavily soiled. Additionally, the kitchen floor was dirty, and the dry storage room had improperly stored items.
The facility failed to provide palatable food at safe temperatures, affecting 107 residents. Observations showed food was often served below required temperatures, and residents reported meals as cold and unappetizing. Food was transported in non-insulated carts, contributing to the issue, and some meals did not meet dietary preferences or restrictions.
The facility failed to maintain cleanliness and proper maintenance, affecting 107 residents. Observations revealed soiled fans, leaking fixtures, stained ceiling tiles, and damaged surfaces in various areas, including resident rooms and common areas. The facility's policies on housekeeping and maintenance were not effectively implemented, as evidenced by the lack of specific entries in the work order system for the observed issues.
A facility failed to ensure complete advance directive documentation for a resident with complex medical conditions. The resident's Code Status document, signed by a guardian, lacked a date for one witness's signature and was missing a second witness's signature. The social worker responsible could not explain the incomplete documentation, which did not comply with the facility's policy requiring two witness signatures.
A facility failed to complete a PASARR for a resident with mental health diagnoses after the 30-day exemption period and did not notify the state mental health authority. The resident was marked as a hospital exemption discharge, but no updated PASARR or referral was made after the exemption lapsed, as confirmed by the social worker.
A facility failed to properly communicate and document hospice services for a resident with severe cognitive impairment and multiple diagnoses, leading to a lack of coordinated care. Despite a physician's order for hospice services, the resident's plan of care and Kardex lacked details on the specific services and their frequency. Interviews with staff revealed a lack of clarity and documentation, and the hospice agency's absence from care conferences further highlighted the deficiency.
Inadequate Infection Control Practices in Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the condition and use of two resident shower rooms. In the shower room across from a specified resident room, observations showed soiled linen on the floor next to a cabinet, three empty and unlabeled shampoo bottles on the shower assist bar, an unused brief placed on the back of the sink, and a black comb with hair present that was not labeled with any resident’s name and was stored on top of the paper dispenser. On a subsequent observation of the same shower room with the DON, surveyors again noted soiled resident clothing and towels on the floor, a soiled towel on the shower stretcher, an unused brief on the back of the sink, and the same unlabeled black comb with hair on top of the paper dispenser. The DON stated that soiled linen and resident clothing should not be placed on the floor, that resident personal items should be labeled, and that these conditions did not meet infection control standards of practice. In the shower room across from the coffee shop, surveyors observed a hand-sized pile of dark-colored hair on the shower floor near the drain, missing corner tile in the shower, and missing tile near the toilet paper dispenser. On a later observation of this same shower room with the DON, surveyors found a used bottle of shampoo and a bottle of body cleanser on the assist bar without resident names, an uncovered toilet bowl plunger resting directly on the floor beside the toilet, and the same areas of missing tile. The DON explained that the missing tile prevented the shower and area near the toilet from having a cleanable surface and that the toilet plunger should have been placed in a bag rather than sitting on the floor.
Failure to Provide Scheduled Showers/Baths to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or baths to dependent residents in accordance with their assessed needs and shower schedules. One resident was admitted with multiple medical conditions including aortic valve stenosis, osteoporosis, right foot drop, depression, anxiety, dementia, and other chronic issues. Her MDS dated 12/20/2025 showed moderate cognitive impairment (BIMS 11/15) and a need for partial/moderate assistance with showering/bathing. Facility shower schedules and point of care task (PCT) documentation indicated she was to receive showers every Monday and Thursday on day shift. However, PCT records showed that during multiple weeks in November 2025, December 2025, and January 2026, she received only one shower per week instead of two. The resident’s family member reported she was not receiving showers twice weekly, and the resident herself stated she did not always receive a bath/shower twice a week, though she could not specify the days or times. Another resident, admitted with right-sided paralysis following a stroke, bilateral knee osteoarthritis, depression, abnormal posture, right hand contracture, hypertension, hyperlipidemia, cocaine abuse, nicotine dependence, and chronic kidney disease, was cognitively intact per an MDS BIMS score of 15/15 dated 01/05/2026. The same MDS indicated he required substantial/maximal assistance with showering/bathing. The facility’s shower schedule and PCT documentation showed he was to receive showers every Monday and Thursday on evening shift. Review of his PCT records revealed missed showers during several weeks in November 2025, December 2025, and January 2026, including weeks where no showers were documented or only one of the two scheduled showers was provided, with only a single refusal documented for one missed shower. During interview, this resident reported he did not always receive a bath/shower twice per week. The DON confirmed, after reviewing PCT documentation, that both residents had not received showers as scheduled and could not explain why showers were not completed twice weekly as planned.
Water Management Program Lacked Active Legionella and OPPP Controls
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation of the 300 hall tub room, discolored water was seen coming from the tub and sink. The Maintenance Director stated that staff do not regularly use the room, but he sometimes uses the tub to clean maintenance items. He also stated that the hot water ran at the tub for a few minutes and slowly started to clear up over time. When asked about flushing stagnant lines, he said he had a monthly work order to flush the hot water tank, but not specific fixtures. During interview, the Maintenance Director stated that he took free chlorine samples to ensure disinfection in the facility water supply, and records showed a range of concentrations above .2 ppm, which he identified as the control limit. However, when he demonstrated the testing process, phenyl red reagents were being used, which are for pH and not for determining free chlorine concentration. When the manufacturer’s directions were followed, the free chlorine level from the hot water out of the men’s locker room sink was .04 ppm. Review of the facility’s Water Management Plan found no updated risk assessment showing a facility description of water flow and building design, and the Water Management Program, last revised 2/1/2024, stated that developing and maintaining a water management program requires continuous review and that building water systems should be described using flow diagrams and a written description.
Hot Water Temperatures Exceeded Safe Limits
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. During observation of the boiler room in the service hall, the outgoing water temperature to resident care areas was 133 F. The Maintenance Director stated that domestic water is usually run at about 110 F because it is tempered with point-of-use mixing valves at each faucet. In the 300 Hall shower room, both showers reached 130 F and the sink measured 112 F when tested with a rapid read thermometer. The Maintenance Director stated that he tested about 15 fixtures each week, which meant each fixture was checked about once every two months, and that the showers were not part of the regular temperature checks because his focus had been on resident room fixtures. In the 100 Hall shower room, one of the two showers reached 130.8 F when tested, and the Maintenance Director stated he would start adding the showers to temperature checks and adjust the mixing valves inside the shower fixtures.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment based on multiple observations throughout the building. In the kitchen, four main exhaust ventilation filters for the cook line were found ajar with gaps between some filters. In the 100 Hall shower room, dried brown and black smudges were observed on the privacy curtain for the commode, and later both shower curtains in that room were noted to have discoloration on a large portion of the bottom sections with black spotted debris. In the 100 Hall rooftop Mr. Slim unit and the 300 Hall rooftop Mr. Slim unit, black spotted debris was observed on the plastic guard and grates where air is expelled. In the 400 Hall linen closet, blankets and pillows were stored on the bottom of open wire rack shelving without a bottom barrier to protect clean linens from contamination due to cleaning. Additional observations included hair and debris on the floor and drain of the 200 Hall shower room, along with a used washcloth in the sink. In the laundry room, two carts used to move clean linen through the washing and drying process had an increased accumulation of paper, plastic trash, and dirt debris under their bottom support floor. The 300 Hall shower room had a strong odor, a yellowish puddle near the front of the commode, and a heavily discolored black accumulation on the underside of the shower bed. A resident room window sill had a broken tile with sharp edges and an accumulation of dust and dead insects. The main dining room sitting area had a brown love seat with heavy orange and pink staining underneath the cushion and dirt debris in the side and back crevices. In the 200 Hall mechanical room, a mop sink faucet had a warm cold-water handle, indicating hot water was bleeding into the cold-water supply from that fixture. Housekeeping Manger J stated staff try to get to each privacy curtain once a month or as needed.
Advance Directive Witnessing Error
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for one resident reviewed for advance directives. Resident #110 was admitted with chronic kidney disease and had a BIMS score of 13 out of 15, indicating cognitive intactness. The clinical record showed the resident signed an advance directive for Do Not Resuscitate on June 11, 2025, but the signature was not witnessed by two persons as required. The form contained one witness signature dated June 11, 2025, and a second witness signature dated June 12, 2025. During an interview on 09/17/2025, an LPN offered no explanation for signing as a witness to the signature after the fact.
Inaccurate PASRR Coding on MDS Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, R30, on the Annual MDS item A1500 regarding Preadmission Screening and Resident Review (PASRR). R30 was admitted and later readmitted to the facility with diagnoses including left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder, and major depressive disorder. The Quarterly MDS with an ARD of 8/9/25 reflected severe cognitive impairment on the BIMS and upper extremity impairments on both sides. R30’s medical record included an OBRA Level II evaluation dated 11/27/24, and the Annual MDS with an ARD of 2/6/25 coded A1500 as No. During interview, the MDS Nurse stated the response was coded by reviewing the OBRA letter and reported the letter did not state that R30 had a serious mental illness, adding that schizophrenia did not qualify as a serious mental illness for the MDS and that they were looking for conditions such as epilepsy and developmental delay. However, the Comprehensive Level II Evaluation for 11/2024 was marked for mental illness and listed DSM diagnoses of schizoaffective disorder, unspecified as primary and unspecified neurocognitive disorder as secondary.
Failure to Coordinate CMH Level II Evaluation Review
Penalty
Summary
The facility failed to ensure coordination of care with Community Mental Health (CMH) for one resident. The resident was admitted and later readmitted with diagnoses including left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder, and major depressive disorder. The Quarterly MDS with an ARD of 8/9/25 showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and upper extremity impairments on both sides. The resident’s medical record included a document dated 11/27/24 reflecting that an OBRA Level II Evaluation had been completed, but the Level II Evaluation itself was not present in the medical record. During interviews, the SWs stated that CMH provided copies of Level II Evaluations for review and then scanning into the record, but when asked about this resident’s Level II Evaluation, they said they would find out. Later, one SW reported that CMH had emailed a copy after the interview and that he would scan it into the medical record, and he acknowledged he had not yet read or reviewed it. The resident’s Level II Evaluation listed proposed programs/objectives for treatment planning, including assessment by therapy to determine whether the resident could use a cup with a handle or another option for independent fluid consumption and further evaluation for a neurocognitive disorder.
Failure to Implement Care Plan for Palm Protectors
Penalty
Summary
The facility failed to implement R30’s care plan for bilateral palm protectors. R30 was admitted and later readmitted with diagnoses including left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder, and major depressive disorder. The Quarterly MDS dated 8/9/25 reflected severe cognitive impairment with a BIMS score of 3 out of 15 and upper extremity impairments on both sides. R30’s care plan directed that palm protectors be worn to both hands during the day as tolerated, and that they could be removed for hygiene, meals, and at night. On 09/16/25, R30 was observed in a broda chair in the dining room with the left hand flexed into a fist and the right hand flexed with the index finger extended, and no palm protectors were in place. On 09/18/25, R30 was observed in bed with eyes closed and again had no palm protectors in place. During interview, CNA F stated they did not routinely care for R30, were not aware of any orthotic devices the resident was to wear, and did not recall seeing palm protectors listed on the Kardex, although the Kardex reflected bilateral palm protectors were to be worn during the day as tolerated.
Failure to Provide Effective Bowel Management
Penalty
Summary
The facility failed to provide an effective bowel management program for one resident, who was admitted with diagnoses including muscle weakness and difficulty walking and had moderately impaired cognition on the MDS. The resident reported on observation that he had not wanted to eat more because the food made him constipated and stated that he had been constipated for about a month. He also reported that he was not aware of receiving medication to help with constipation. Review of the resident’s task log showed multiple spans of days with no documented bowel movement, including 4 days, 2 days, 2 days, and 3 days across August and September. Physician orders included PRN Miralax every 24 hours for constipation and PRN Milk of Magnesia daily for constipation, but the MAR showed Miralax was given only twice and Milk of Magnesia was not administered in August or September. There was no additional documentation in the progress notes or MAR showing that the resident was offered medication or other interventions for constipation. The DON stated the facility expected an intervention if there was no bowel movement for 3 days and that the facility did not have a structured bowel management program or associated policy.
Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act 42CFR483. This deficiency was identified during a review of an incident involving two residents, where one resident, with a history of behavioral issues, struck another resident on her recently operated left arm. The incident was not reported to the state, and the investigation was incomplete, with several areas left blank and lacking documentation of the incident's details and outcomes. The affected resident, who had a moderate cognitive impairment and required assistance with daily activities, reported being hit by another resident while in her wheelchair. The incident caused her pain, and an X-ray was ordered due to the recent surgery on her left arm. Despite the resident's complaint and the subsequent medical assessment, the incident was not properly documented in the nursing progress notes, and the investigation was not completed or reported to the state authorities. The resident who struck the other had a history of behavioral problems, including aggression towards staff and other residents. His care plan noted these issues, but it was not updated following the incident. The facility's failure to document the incident properly, investigate it thoroughly, and report it to the state reflects a significant lapse in adhering to required protocols for handling and reporting suspected abuse or neglect within the facility.
Failure to Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, resulting in known allegations of abuse going uninvestigated and the potential for further abuse without intervention or protection. One resident, who had a history of falling and a recent fracture, reported being hit on her injured arm by another resident. Despite the resident's complaint of pain and the incident being reported to staff, the incident was not properly documented or reported to the state, and the investigation was incomplete. The incident report completed by an LPN did not include critical details such as the results of an X-ray ordered for the injured resident's shoulder. Interviews with staff revealed inconsistencies in the handling of the incident, with some staff members acknowledging the need for new interventions to prevent recurrence, while others did not document the incident in the resident's care plan. The facility's failure to document and report the incident properly indicates a lack of thorough investigation and follow-up. The resident who allegedly caused the incident had a history of behavioral issues, including aggression towards staff and other residents. Despite this, the care plan for the resident was not updated following the incident, nor were new interventions implemented to address the behavior. The lack of documentation and failure to update the care plan for the resident with behavioral issues further highlights the facility's inadequate response to the incident and the potential risk to other residents.
Insufficient Dietary Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient staffing in the Dietary Services department, affecting 107 residents and leading to delays in meal preparation and delivery. During a comprehensive tour of the food service area, it was observed that additional staff from another regional corporate facility were assisting with breakfast meal preparation and delivery. The Dietary Manager confirmed that the facility was understaffed, missing one dietary staff member and two dietary aides, which contributed to the delays. Several residents reported receiving their meals significantly later than scheduled. One resident, who was cognitively intact, reported receiving breakfast after 10:00 AM, despite it being scheduled for 8:30 AM. Another resident, also cognitively intact, reported frequent delays in meal service, with breakfast sometimes arriving as late as 11:00 AM and lunch at 2:30 PM. Additionally, it was noted that the facility occasionally resorted to ordering pizza from an outside vendor to provide meals to residents, indicating a persistent issue with meal service timeliness.
Deficiencies in Food Service Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the food service area, affecting 107 residents. Observations revealed that the flooring surfaces in the kitchen were soiled with accumulated dust, dirt, and grease. The wall/floor junctures, corners, and entrance door frame cavities were also observed to be dirty. Additionally, the emergency eye wash station receptacle and the entrance door exterior surface between the Main Dining Room and Food Production Kitchen were found to be soiled with dust and grime. The mechanical dish machine was observed to have a wash temperature gauge reading of 136 degrees Fahrenheit and a final rinse temperature gauge reading of 176 degrees Fahrenheit, with a PSI gauge reading of 0 psi during the final rinse cycle. Although the thermal verification tape indicated proper sanitization, the flow pressure did not meet the required standards. Furthermore, a water supply valve was leaking above the ice machine in-line filter, and the Crown steamer copper drain line connection was leaking water onto the floor near an electrical supply line. The service sink faucet was also loose-to-mount. Food storage practices were inadequate, with an open gallon of milk lacking an effective open or out date mark. The Juice Machine, South Bend convection oven, Vulcan hot box, and Amana microwave oven were all observed to be soiled with food residue. The return-air-exhaust ventilation grill was heavily soiled with dust and dirt deposits. Additionally, the kitchen floor was observed to be soiled with a black substance, and water was present under the tray line table. The walk-in freezer contained a boxed pie crust with a frozen clear substance on the outside, and the dry storage room had multiple boxes on the floor, including torte shells and open boxes of cups and napkins, with the floor visibly soiled.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide palatable food products for seven reviewed residents, affecting a total of 107 residents. Observations and interviews revealed that food was often served at temperatures below the required standards set by the 2017 FDA Model Food Code. For instance, the temperature of chicken teriyaki was recorded at 120.8 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit. Additionally, residents reported that their meals were frequently served lukewarm or cold, with some expressing dissatisfaction with the taste and quality of the food. The report highlights specific instances where food was transported in non-insulated carts, which likely contributed to the inadequate temperatures upon arrival at the residents' rooms. Residents consistently reported that their meals were not only cold but also unappetizing, with some meals not meeting dietary preferences or restrictions. For example, a resident on a mechanical soft diet received a dinner roll instead of a spring roll, and another resident received bread and green vegetables despite dietary guidance to exclude these items. Interviews with residents further confirmed the issue, with several residents expressing dissatisfaction with the temperature and quality of their meals. One resident mentioned that the food was "stone cold," while another described it as "yuck." The facility's policies on food handling and tray accuracy were reviewed, revealing that there were procedures in place to ensure proper food temperatures and tray accuracy, but these were not effectively implemented, leading to the deficiencies observed.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 107 residents. During an environmental tour, several areas were found to be inadequately maintained. In the beauty shop, a desk fan was observed with accumulated dust and dirt. In the 100 Hall shower room, return-air-ventilation grills were heavily soiled, and the ambulance entrance/exit door had a worn door sweep, creating an open space. The 200 Hall restroom had a leaking commode base standpipe supply line, and the main dining room had stained ceiling tiles. The center nursing station's floor fan was also soiled. In the 300 Hall, the janitor closet's mop sink basin and return-air-exhaust ventilation grill were heavily soiled. The tub room had a leaking hot water supply handle, and the shower room's ventilation grill was soiled. Sampled resident rooms revealed various issues, including loose paper towel dispensers, soiled fans, non-functional light assemblies, and soiled bedding. Several rooms had damaged drywall surfaces, loose vinyl coving strips, and etched restroom entrance door surfaces. Additionally, some restroom hand sink basins were draining slowly. The facility's housekeeping and maintenance policies were reviewed, revealing a lack of specific entries related to the observed maintenance concerns in the Direct Supply TELS Work Orders for the last 60 days. The housekeeping policy emphasized thorough scrubbing and routine cleaning of horizontal surfaces, while the maintenance policy aimed to assure proper maintenance of the physical plant. However, the observations indicated that these policies were not effectively implemented, leading to the deficiencies noted during the survey.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for a resident who was admitted with multiple complex medical conditions, including Huntington's Disease, dementia, and epilepsy. The resident, who had a court-appointed guardian, had a Resident Code Status document that was incomplete. The document, dated January 15, 2024, was signed by the guardian but lacked the required date for one witness's signature and was missing a second witness's signature entirely. During an interview, the social worker responsible for coordinating advance directives admitted that it was her responsibility to ensure the Resident Code Status document was completed in its entirety, including signatures and dates from two witnesses. However, she could not explain why the document for this resident was incomplete. The facility's policy on advance directives required a Code Status Form to be completed by the resident and signed by two witnesses and a physician, which was not adhered to in this case.
Failure to Complete PASARR After 30-Day Exemption
Penalty
Summary
The facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed for a resident after the 30-day exemption period and did not notify the State mental health authority. The resident was admitted with diagnoses including major depressive disorder, anxiety, bipolar disorder, post-traumatic stress disorder, and schizophrenia. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The PASARR Level I screening marked the resident as a hospital exemption discharge, indicating a likely need for less than 30 days of nursing services. However, after the 30-day exemption period lapsed, the facility did not complete an updated PASARR or refer the case to the state mental health authority, as confirmed by the social worker who lacked documentation of these actions.
Deficiency in Hospice Service Coordination and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including protein-calorie malnutrition, palliative care needs, and severe cognitive impairment, was observed denying receipt of hospice services. Despite a physician's order for hospice evaluation and treatment, the resident's plan of care lacked details on the specific hospice services and their frequency. The Kardex also failed to include this information, indicating a gap in communication and documentation. Interviews with facility staff, including an LPN, Nurse Manager, and DON, revealed a lack of clarity and documentation regarding the hospice services provided to the resident. The LPN was unaware of the specific services or their frequency, and the Nurse Manager could not provide a hospice calendar or explain the absence of service details in the plan of care. Additionally, the Care Conference Minutes did not show attendance by the hospice agency, further highlighting the deficiency in coordination and communication of hospice services for the resident.
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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 Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Battle Creek | 2.4 mi | ★★★★★ | 12 | 0 |
| The Oaks At Battle Creek | 2.6 mi | ★★★★★ | 0 | 0 |
| Evergreen Manor Senior Care Center | 2.7 mi | ★★★★★ | 19 | 0 |
| Pinnacle Care Of Battle Creek | 4.2 mi | ★★★★★ | 15 | 0 |
| Calhoun County Medical Care Facility | 6 mi | ★★★★★ | 5 | 0 |
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