Inspection Reports for
Bedford Springs Health and Rehabilitation
50 SHEPHERD LANE, BEDFORD, KY, 40006
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Bedford Springs Health and Rehabilitation.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Life Safety
Census: 50
Capacity: 58
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to maintain an Emergency Preparedness Program (EPP) reviewed and updated annually.
Failed to maintain and update the Emergency Preparedness Plan based on all hazards risk assessment.
Failed to develop and maintain an emergency preparedness communication plan updated at least every 2 years.
Egress doors equipped with delayed egress locks lacked audible alarms when activated.
Portable space heaters used in the facility did not comply with NFPA standards.
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
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding delayed egress door alarms and portable space heaters; verified findings during exit conference on 04/09/2025. | |
| Administrator | Interviewed regarding Emergency Preparedness Program, Communication Plan, Hazard Risk Assessment, and Life Safety findings; verified findings during exit conference on 04/09/2025. | |
| Senior Administrator | Educated Administrator on requirements for Emergency Preparedness Manual and Communication Plan updates. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 8, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident was not discharged without adequate reason and proper documentation.
Complaint Details
The complaint involved Resident #341 being discharged against medical advice without adequate documentation or appropriate discharge planning. The resident exhibited behavioral issues related to delirium post-surgery, and the facility failed to provide sufficient interventions or alternative discharge options. The discharge was not supported by physician approval or proper documentation.
Findings
The facility failed to ensure that Resident #341 was permitted to remain at the facility and was discharged without adequate reason or documentation. The facility also failed to provide appropriate interventions for the resident's behavioral issues prior to discharge. Additionally, deficiencies were found in medication storage security and food storage safety.
Deficiencies (3)
F 0622: The facility discharged Resident #341 without adequate reason or documentation, failing to ensure the resident's welfare was met and did not provide appropriate discharge planning or alternatives.
F 0761: The facility failed to ensure refrigerated scheduled medication boxes were affixed to the medication refrigerator and the emergency medication kit was not secured within an affixed box or area.
F 0812: The facility failed to maintain safe food storage temperatures; the walk-in cooler temperature was 58 degrees Fahrenheit, exceeding safe limits and risking foodborne illness.
Report Facts
Residents sampled: 28
Residents affected: 1
Walk-in cooler temperature: 58
Walk-in cooler temperature: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Provided care to Resident #341 and reported on resident's behavior and interventions |
| Social Services Director | Social Services Director | Involved in discharge planning and signed discharge against medical advice form for Resident #341 |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #341's referral and discharge decisions |
| Administrator | Administrator | Provided interviews about facility policies and Resident #341's discharge |
| Consultant Pharmacist #1 | Consultant Pharmacist | Checked medication storage and compliance during monthly visits |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication storage and narcotic box security |
| Registered Nurse #2 | Registered Nurse | Reported on medication storage security and documentation |
| Director of Dietary | Director of Dietary | Interviewed regarding food storage temperature issues and food safety |
| Dietitian | Dietitian | Interviewed about monitoring refrigerator temperatures and food safety |
| Dietary Aide #1 | Dietary Aide | Observed and reported on walk-in cooler temperature and food handling |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 13, 2018
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, treatment, safety, and infection control at Bedford Springs Health and Rehabilitation.
Findings
The facility failed to implement complete care plans, provide diabetic shoes as ordered, follow physician wound care orders, maintain a hazard-free environment, and maintain an effective infection control program. Several residents, including Resident #45 and Resident #18, were affected by these deficiencies.
Deficiencies (5)
F 0656: The facility failed to develop and implement a complete care plan for Resident #45 related to diabetic foot care, including timely provision of diabetic shoes.
F 0684: The facility failed to follow physician orders for wound care for Resident #45, including improper application of wound dressings and inaccurate transcription of orders in the EMR.
F 0687: The facility failed to provide diabetic shoes per physician order for Resident #45, resulting in delayed treatment and potential harm.
F 0689: The facility failed to maintain a hazard-free environment by not repairing a wobbly footboard on Resident #18's bed, which posed a fall risk.
F 0880: The facility failed to maintain an effective infection control program, including improper use and disposal of PPE and failure to provide biohazard waste receptacles in isolation rooms.
Report Facts
Residents sampled: 13
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in wound care observation and infection control deficiencies |
| LPN #1 | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in wound care and diabetic shoe deficiencies |
| CNA #1 | Certified Nursing Assistant | Named in care plan and infection control deficiencies |
| CNA #2 | Certified Nursing Assistant | Named in infection control deficiencies |
| Social Services Director | Named in diabetic shoe procurement deficiencies | |
| Director of Nursing | DON | Named in multiple deficiencies including care plan, wound care, diabetic shoes, and infection control |
| Assistant Director of Nursing | ADON | Named in care plan, diabetic shoe, and infection control deficiencies |
| Maintenance Director | Named in hazard environment deficiency | |
| Regional Plant Operation Director | Named in hazard environment deficiency | |
| Administrator | Named in overall facility oversight and deficiencies | |
| Chaplain | Named in infection control deficiency for improper PPE use |
Viewing
Loading inspection reports...
