The Laurels of Bedford

Inspectors wroteThis citation pertains to Intake: 2960508Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (R2) out of three residents with pressure ulcers reviewed, resulting in the development of three facility acquired stage 3 pressure ulcers (full thickness tissue loss) and worsening of one stage 3 pressure ulcer present on admission to stage 4 (full thickness tissue loss with exposed bones and or tendons) that required hospital transfer for osteomyelitis (wound and bone infection), pain, and debridement.

Inspectors wroteThis citation Pertains to Intake 2989698. Based on interview and record review the facility failed to follow a physician order to administer an anti-seizure medication for one resident (Resident #4) of one resident reviewed for seizure medication.

Inspectors wroteThis citation pertains to intake: 2685213Based on observation and interview, the facility failed to maintain infection control practices for two resident shower rooms out of three resident shower room observations. Findings Included:On 01/27/2026 at 09:35 a.m. during observation of shower room (across form room [ROOM NUMBER]) the following was observed: soiled linen was on the floor, next to a cabinet, 3 empty bottles of shampoo on the assist bar of the shower and not labeled for any resident, an unused brief on the back of the sink, a black comb with hair present and not labeled with any resident name on top of the paper dispenser. On 01/27/2026 at 11:55 a.m. during observation of shower room (across from coffee shop) the following was observed: [...]

Inspectors wroteThis citation pertains to intact 2685213Based on observation, interview, and record review, the facility failed to provide showers/baths for two Residents (#1, #5) of three Residents reviewed. Findings Included:Resident #1 (R1):Review of the medical record demonstrated that R1 was admitted to the facility on [DATE] with diagnoses that included aortic valve stenosis, dry eye syndrome of bilateral lacrimal glands (lack of tears), hyperlipidemia (high fat content in blood), rectal prolapse (a condition where the rectum protrudes from the anus), osteoarthritis (degenerative joint disease) right ankle and foot, repeated fails, osteoporosis (weak and brittle bones), right foot drop, depression, peripheral venous insufficiency, hypothyroidism (low thyroid hormone), borderline personality disorder, anxiety, and dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents in the facility. Findings Include:On 9/16/25 at 1:42 PM, with Maintenance Director (MD) H, Observation of the boiler room in the service hall found that the outgoing water temperature to resident care areas was showing 133F. An interview with MD H found that water temperatures for domestic use usually run around 110F as they are tempered with point of use mixing valves at each faucet. On 9/16/25 at 2:01 PM, Observation of the 300 Hall shower room found that both showers reached 130F and the sink was 112F when tested with a rapid read thermometer. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/16/25 at 9:50 AM, Observation of the kitchen main exhaust ventilation for the cook line found four ventilation filters ajar from position as well as having gaps between some of the filters. Filters should be placed snug and tight together to effectively filter out grease. On 9/16/25 at 11:14 AM, Observation of the 100 Hall shower room found dried brown and black smudges on the privacy curtain for the commode. On 9/16/25 at 11:17 AM, Observation of the 100 Hall [redacted] rooftop unit found an accumulation of black spotted debris on the surface of the plastic guard and grates where air is expelled. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#110) of one resident reviewed for advance directives from a total sample of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (R30) of 23 reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care with Community Mental Health (CMH) for one (R30) of one reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the Care Plan for one (R30) of 23 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an effective bowel management program for one (Resident #64) of one reviewed, resulting in the potential for constipation. Review of the clinical record revealed R64 was admitted into the facility on 7/1/25 with diagnoses that included: muscle weakness and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R64 scored 11/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition). On 9/16/25 at 12:41 PM R64 was observed lying on his side in bed. R64's lunch tray was observed on his tray table with only a few bites gone. R64 reported that he didn't want to eat more because the food made him constipated. He further reported that he had suffered from constipation for about a month. [...]

Inspectors wroteThis citation pertains to Intake #MI00149504 Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c)

Inspectors wroteThis citation pertains to Intake #MI00149504 Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for one of two residents (R1, R9) reviewed for abuse from a total sample of nine; resulting in known allegations of abuse to go uninvestigated and the potential for abuse to occur with no intervention or protection.

Inspectors wroteBased on observations and interviews, the facility failed to provide sufficient staffing related to Dietary Services effecting 107 residents, resulting in the increased likelihood for delayed meal preparation and delivery service.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, (2) clean food production kitchen flooring surfaces, (3) properly store and label food products, and (4) effectively date mark potentially hazardous ready-to-eat food products effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide palatable food products for seven of seven reviewed (R4, R29, R72, R84, R85, R99, and R169) effecting 107 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#1) of one resident reviewed for advance directives from a total sample of 22 residents. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30-day exemption period and failed to notify the State mental health authority for one (Resident #97) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper communication/documentation of Hospice services provided to one resident (#45) of one resident reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices for Foley catheters were maintained for two residents (Resident #98 and 17), and infection control surveillance was thoroughly conducted, resulting in the potential for the spread of infections to all 104 residents who resided at the facility. Findings Included: Record review of an infection control surveillance line listing log (list of all infections in the facility) for the month of May 2023 revealed the facility had 33 infections with 10 of the infections being catheter acquired, and 23 being healthcare associated infections. Further review of a June 2023 surveillance log revealed the facility had 46 total infections with 12 being catheter acquired, and 28 being healthcare associated infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely completion of Minimum Data Set (MDS) assessments for four (Resident #16, #20 #68, #112) of 22 reviewed for MDS, resulting in late MDS assessments and the potential for further late assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate coding of Minimum Data Set (MDS) assessments for six (Resident #5, #16, #28, #53, #61 and #68) of 22 reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident food stored in the 400 unit refrigerator, where 10 residents resided, had refrigerator temperatures documented, the expiration dates of food, and resident's names documented on food items, resulting in the potential for food borne illnesses. Findings Included: In an observation on 7/13/2023 at 1:05 PM, with Licensed Practical Nurse (LPN) S in the 400 hall resident food refrigerator revealed that the refrigerator temperature was not recorded for the dates of 7/11 and 7/12/2023. Additionally, the resident food refrigerator did not have a thermometer in it, and therefore the temperature of the refrigerator on inspection was not able to be determined. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide advanced written notice prior to a room change for one Residents (#68), of two residents reviewed for room changes. This deficient practice resulted in the potential for increased anxiety, misunderstanding of the reasons for the room change, and the lack of opportunity for resident to ask questions or express concerns.

Inspectors wroteThis Citation Pertains To Intake #'s MI00136714 and MI00136757 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for three (Resident #110, R#111 and #112) of four reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary information was communicated/provided to the receiving facility upon discharge for two (Resident #75 and #107) of two reviewed for hospital transfer, resulting in the potential for unmet care needs and/or residents to not receive the necessary services to ensure a safe and effective transition of care.

Inspectors wroteThis citation pertains to intake MI00136858. Based on interview and record review, the facility failed to provide a written notice of transfer or discharge for one (Resident #11) of three reviewed for transfer/discharge, resulting in the potential for the Resident not being informed of the reason for transfer and their appeal rights.

Inspectors wroteThis citation pertains to intake MI00136858. Based on interview and record review, the facility failed to provide a bed hold policy upon transfer for one (Resident #11) of three reviewed for transfer/discharge, resulting in the potential for the Resident not being informed of the facility's bed hold policy.

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS) assessments timely for two (Resident #53 and #61) of 22 reviewed for MDS assessments, resulting in the potential for unrecognized and unmet care needs in a current facility census of 104 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive Care Plan for one (Resident #108) of 22 reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #108 Review of the medical record reflected Resident #108 (R108) admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation (irregular heart rate) and type two diabetes mellitus. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/13/23, reflected R108 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R108 was no longer admitted to the facility. Review of R108's medication list revealed she was admitted to the facility on Warfarin (an anticoagulant medication), with a start date of 4/11/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a Care Plan for one resident (Resident #20) and failed to ensure one resident (Resident #82) had Care Conferences resulting in the potential for unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively implement discharge planning for one of two residents (Resident #82) reviewed for discharge planning according to resident specific goals resulting in frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of four residents (Resident #47), who had a Foley catheter (tube inserted into the bladder to drain urine), was appropraitley assessed for the need to continue or discontinue the use of the catheter, resulting in the potential for complication and/or infections. Findings Include: On 7/11/2023 at 11:04 AM, Resident #47 (R47) was observed to have a Foley catheter in place. R47 was asked if she knew why she had the catheter. R47 stated no and wanted the catheter removed. Review of R47's medical diagnosis revealed R47 had a neuromuscular dysfunction (lack of bladder control) of the bladder. Record review of a progress note dated 4/26/2022 revealed, Note Text: Guests indwelling catheter will remain in place r/t (related to) dx (diagnosis) of neurogenic bladder. Continue with current plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services pertaining to discharge planning and room changes (Resident #68) and care conferences (Resident #82) for two of 22 reviewed, resulting in the potential for residents not to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely follow-up for identified pharmacy medication regimen review irregularities for one (Resident #61) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of five residents (Resident #60) had an indication for the use of an antibiotic, resulting in the potential for the over use of antibiotics. Findings Included: Resident #60 Per the facility face sheet R60 was admitted to the facility on [DATE]. Review of a urinalysis (urine test to identify infections) dated 7/10/2023, revealed R60 was potentially positive for an urinary tract infection (UIT). Review of an urine culture and sensitivity (C&S) (second part of urine test that reveals what organism was causing the infection, and what antibiotic would will be effective for treating the UTI) revealed that the results were completed on 7/11/2023, and indicated mixed flora (meaning the sample had been contaminated and a new sample was required). Therefore, no organism nor antibiotic was identified on the C&S report. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen was free of unnecessary psychotropic medications for one (Resident #61) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure expired medications were disposed of, and a refrigerator for medication storage had temperatures documented, resulting in the potential for administration of expired and/or ineffective medications. Finding Included: During a medication storage observation on 7/13/2023 at 2:13 PM, with Licensed Practical Nurse (LPN) Son the 400 rehab hall, it was revealed that the refrigerator where medications were stored did not had the temperature documented for the date of 7/12/23. Further observation with LPN S of the same refrigerator revealed two boxes of influenza vaccination were stored in the refrigerator with other medication, and each box contained 10 pre-filled syringes that had expired on 6/30/2023. [...]