Core of Bedford

In the surveyor’s words

From the most serious findings on record at Core of Bedford, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 22, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident, with a history of smoking in the room, from smoking a cigarette in the residents' room with an operating oxygen concentrator. This resulted in a systemic failure which presented the potential for combustion of oxygen from a burning cigarette and could have caused harm to residents in the room, adjacent rooms, and hallways for 1 of 1 resident randomly observed for accidents (Resident 13) The Immediate Jeopardy began on 4/21/22 when the facility failed to ensure Resident 13 did not smoke a cigarette in the resident's room approximately 6 feet away from Resident 30's oxygen concentrator. […]

• Actual harm, isolatedF693Oct 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary interventions to prevent dislodgement of a gastrostomy tube (feeding tube) for 1 of 1 resident reviewed for feeding tubes. This deficient practice resulted in a hospitalization to remove the G-tube, sepsis, and cannot have a new G-tube placed for 6 weeks. (Resident B) Finding include: On 10/24/25 at 10:40 a.m., Resident B was observed to be sitting in a reclining wheelchair. A yellow nasogastric tube (a flexible tube inserted through the nose and down the throat into the stomach) was observed to have feeding infusing from a feeding pump. On 10/24/25 at 11:05 a.m., Resident B's clinical record was reviewed. […]

• Actual harm, isolatedF600Nov 9, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident (Resident E) was free from abuse by another resident (Resident D) which resulted in an emergency room (ER) visit due to a facial laceration that required wound glue (medical adhesive) for wound closure for 1 of 1 resident reviewed for abuse. (Resident E) Findings include: On 11/9/21 at 11:10 a.m., Resident E was sitting in the dining room. He was observed to have a dime-size laceration (a tear in the skin) on his forehead. On 11/9/21 at 11:30 a.m., Resident D's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's Nurse's Progress notes indicated the following: -On 10/26/21 at 9:00 p.m., Resident D went out back alone. […]

• No harm, potential for more than minimal, widespreadF880Mar 17, 2023

  Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of infections for 34 of 34 residents residing in the building. A water management program was not implemented to prevent water borne pathogens and gloves were not worn while obtaining a blood glucose level. (Resident 4, RN 1) Findings include: 1. On 3/17/23 at 12:00 p.m., the Administrator (ADM) presented the Water Management Binder. The binder contained the Water Borne Pathogen Prevention Policy which indicated the facility would implement a water management program which follows a preventative guide. […]

• No harm, potential for more than minimal, widespreadF921Apr 22, 2022

  Based on observation, interview, and record review, the facility failed to ensure a sanitary environment in 4 of 4 resident shower/bathrooms used by 32 of 32 residents. Toilets were not anchored to the floors, dark substance was around toilet bases, a sink was not anchored to the wall, a floor drain was full of a dark liquid, and an odor of sewage was emitted in shower/bathrooms. (Northeast, Northwest, Southeast, Southwest) Findings include: 1. The Northeast resident shower/bathroom floor drain emitted an odor of sewage on the following dates and times: - 4/19/22 at 10:00 A.M., 12:20 P.M., and 3:10 P.M. - 4/20/22 at 11:15 A.M. and 2:50 P.M. - 4/21/22 at 10:15 A.M. and 3:00 P.M. - 4/22/22 at 11:30 A.M. and 2:00 P.M. 2. […]