Inspection Reports for Bedford Springs Health and Rehabilitation

50 SHEPHERD LANE, KY, 40006

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Inspection Report Summary

The most recent inspection on April 9, 2025, identified deficiencies related to emergency preparedness and life safety code compliance. Earlier inspections were not provided for comparison, so it is unclear if these issues represent a new or ongoing pattern. The main deficiencies involved failure to maintain and update emergency preparedness plans and communication, as well as life safety concerns including delayed egress door alarms and noncompliant portable space heaters. No complaint investigations or enforcement actions such as fines or license suspensions were listed in the available reports. The facility achieved substantial compliance shortly after this inspection, indicating corrective actions were implemented.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025
Inspection Report Life Safety Census: 50 Capacity: 58 Deficiencies: 5 Apr 9, 2025
Visit Reason
An Emergency Preparedness Recertification Survey and a Life Safety Recertification Survey were conducted to assess compliance with federal regulations and requirements for long term care facilities, including emergency preparedness and life safety code compliance.
Findings
The facility was found not to be in compliance with emergency preparedness requirements, including failure to maintain and update the Emergency Preparedness Program, Communication Plan, and Hazard Risk Assessment annually. Life Safety deficiencies included improper egress door locking arrangements, lack of audible alarms on delayed egress doors, and use of portable space heaters not meeting NFPA standards. The facility achieved substantial compliance with Life Safety Code on 05/05/2025 after a plan of correction.
Severity Breakdown
SS=F: 3 SS=D: 2
Deficiencies (5)
DescriptionSeverity
Failed to maintain an Emergency Preparedness Program (EPP) reviewed and updated annually.SS=F
Failed to maintain and update the Emergency Preparedness Plan based on all hazards risk assessment.SS=F
Failed to develop and maintain an emergency preparedness communication plan updated at least every 2 years.SS=F
Egress doors equipped with delayed egress locks lacked audible alarms when activated.SS=D
Portable space heaters used in the facility did not comply with NFPA standards.SS=D
Report Facts
Facility capacity: 58 Census: 50 Survey dates: Emergency Preparedness and Life Safety surveys conducted 04/09/2025 to 04/10/2025 Sample size: 41 Supplemental residents: 8
Employees Mentioned
NameTitleContext
Maintenance DirectorInterviewed regarding delayed egress door alarms and portable space heaters; verified findings during exit conference on 04/09/2025.
AdministratorInterviewed regarding Emergency Preparedness Program, Communication Plan, Hazard Risk Assessment, and Life Safety findings; verified findings during exit conference on 04/09/2025.
Senior AdministratorEducated Administrator on requirements for Emergency Preparedness Manual and Communication Plan updates.

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