Inspection Reports for Core of Bedford
514 16th St, Bedford, IN 47421, IN, 47421
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Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Jun 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460911.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460911 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 33
Other Payor Residents: 1
Inspection Report
Re-Inspection
Census: 32
Capacity: 37
Deficiencies: 0
May 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/17/2025 was performed to verify compliance with previous deficiencies.
Findings
At this PSR survey, Core of Bedford was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for one detached shed used for storage.
Report Facts
Facility capacity: 37
Census: 32
Inspection Report
Re-Inspection
Census: 28
Capacity: 28
Deficiencies: 1
Apr 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed February 20, 2025, and was conducted in conjunction with a PSR to the Investigation of Complaint IN00454567 completed on March 6, 2025.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey. Complaint IN00454567 was corrected. A continuing annual waiver was approved for the requirement of at least 100 square feet in single resident rooms.
Complaint Details
Complaint IN00454567 was investigated and corrected as of this visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Bedrooms measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; this requirement is not met as evidenced by a continuing annual waiver approved. | SS=D |
Report Facts
Census SNF/NF: 28
Total Capacity: 28
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 8
Inspection Report
Re-Inspection
Census: 28
Capacity: 28
Deficiencies: 0
Apr 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00454567 completed on March 6, 2025, conducted in conjunction with a PSR to the Recertification and State Licensure Survey completed February 20, 2025.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaint IN00454567. The complaint was corrected.
Complaint Details
Complaint IN00454567 was investigated and found to be corrected as of this visit.
Report Facts
Census SNF/NF: 28
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 8
Inspection Report
Annual Inspection
Census: 28
Capacity: 37
Deficiencies: 3
Mar 17, 2025
Visit Reason
An Emergency Preparedness Recertification, Life Safety Code Recertification, and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements and state licensure regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to conduct annual 90-minute testing of battery backup emergency lighting, combustible decorations on a resident room corridor door exceeding allowed limits, and improper use of extension cords and power strips as substitutes for fixed wiring in patient care areas.
Severity Breakdown
SS=F: 1
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 battery backup light was tested annually for 90 minutes and maintain written records of visual inspections and tests. | SS=F |
| Failed to ensure 1 of 18 resident room corridor doors was maintained without combustible decorations exceeding allowed limits. | SS=E |
| Failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring within patient care vicinity. | SS=D |
Report Facts
Certified beds: 37
Census: 28
Resident room corridor doors: 18
Percentage coverage: 90
Audit period: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Reviewed findings at exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 2
Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454567, which involved federal and state deficiencies related to allegations concerning resident care and documentation.
Findings
The facility failed to notify a resident's representative of significant weight loss and failed to document a fall for the same resident. The resident involved was deceased, and systemic changes including staff in-service and quality assurance audits were planned to address these issues.
Complaint Details
Complaint IN00454567 was substantiated with federal and state deficiencies cited at F580 and F842 related to failure to notify a resident's representative of significant weight loss and failure to document a fall.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident's representative was notified of an assessed significant weight loss for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents. | SS=D |
Report Facts
Census: 30
Total Capacity: 30
Weight loss percentage: 18.59
Weight loss percentage: 12.4
Residents audited weekly: 5
Records monitored weekly: 10
Records monitored biweekly: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Signed the report and provided facility policies during the investigation |
| Minimum Data Set Coordinator (MDS) | Interviewed regarding Resident B's weight loss and fall history | |
| RN 1 | Registered Nurse | Interviewed and indicated knowledge of Resident B's fall and subsequent X-ray orders |
| Director of Nursing | Responsible for conducting quality assurance audits related to weight loss and fall documentation |
Inspection Report
Renewal
Census: 30
Capacity: 30
Deficiencies: 5
Feb 20, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 17 to 20, 2025.
Findings
The facility was found deficient in several areas including inaccurate documentation of residents' advanced directives, inaccurate resident assessments, unlabeled oxygen tubing, improper food storage, and inadequate room size in multiple occupancy rooms. Plans of correction and systemic changes were implemented for each deficiency.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives. | SS=D |
| Failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment (PASARR Level II documentation). | SS=D |
| Failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care. | SS=D |
| Failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations. | SS=E |
| Failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms (Rooms 3, 6, and 8). | SS=D |
Report Facts
Census: 30
Total Capacity: 30
Deficiencies cited: 5
Room size measurements: 76
Room size measurements: 78
Room size measurements: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Interviewed regarding advanced directive documentation and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00448728 completed on January 17, 2025.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00448728 was investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 1
Jan 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00448728 regarding allegations related to medication reconciliation and controlled substances.
Findings
The facility failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed (Resident B). There was a discrepancy in the controlled substance inventory and missing pills that were not properly documented or disposed of according to policy.
Complaint Details
Complaint IN00448728 was substantiated with federal/state deficiencies cited at F755 related to medication reconciliation and controlled substance management.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure accurate reconciliation and disposition of controlled substances for Resident B. | SS=D |
Report Facts
Census: 30
Total Capacity: 30
Medicare Residents: 3
Medicaid Residents: 20
Other Residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan M Jordan | HFA | Facility representative signing the report |
| LPN 1 | Nurse identified during investigation related to medication discrepancy | |
| Director of Nursing | DON | Conducted audit and identified medication discrepancy |
| Administrator | ADM | Notified of missing pills and provided facility policy |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448194.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00448194 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 31
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Sep 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00436577 and IN00441957 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in Complaints IN00436577 and IN00441957 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B, including the COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00436577 and Complaint IN00441957 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 31
Total Capacity: 31
Medicare Census: 2
Medicaid Census: 24
Other Payor Census: 5
Inspection Report
Follow-Up
Census: 30
Capacity: 37
Deficiencies: 0
Aug 5, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Recertification and State Licensure Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/16/24.
Findings
At this PSR survey, Core of Bedford was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR Subpart 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for one detached shed used for storage.
Report Facts
Certified beds: 37
Census: 30
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435407.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00435407 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 6
Inspection Report
Annual Inspection
Deficiencies: 0
May 28, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure Survey completed on April 26, 2024.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Census: 33
Capacity: 37
Deficiencies: 5
May 16, 2024
Visit Reason
An Emergency Preparedness Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and life safety code standards.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, failed to conduct required fire drills with verification of alarm transmission, did not complete annual fire door inspections, lacked documentation of electrical receptacle testing, and missed weekly generator inspection records for several weeks.
Severity Breakdown
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. | — |
| Failed to ensure 1 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station. | SS=F |
| Failed to ensure annual inspection and testing of at least one fire door assembly was completed. | — |
| Failed to ensure documentation of electrical outlet receptacle testing for all resident sleeping rooms was available. | SS=F |
| Failed to ensure a written record of weekly inspections for the generator was maintained for 6 of 52 weeks. | — |
Report Facts
Certified beds: 37
Census: 33
Fire drills reviewed: 12
Fire drills missing verification: 1
Weeks missing generator inspection records: 6
Inspection Report
Renewal
Census: 33
Capacity: 33
Deficiencies: 1
Apr 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over April 23-26, 2024.
Findings
The facility failed to provide at least 80 square feet per resident in multiple occupancy rooms for 3 of 18 resident rooms (Rooms 3, 6, and 8). However, these rooms had variance waivers in place and were licensed for double occupancy with two beds each.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 3 of 18 resident rooms (Room 3, Room 6, Room 8). | SS=D |
Report Facts
Number of beds in Room 3: 2
Number of beds in Room 6: 2
Number of beds in Room 8: 2
Square feet per resident in Room 3: 76.59
Square feet per resident in Room 6: 78.99
Square feet per resident in Room 8: 76.48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Laboratory Director or Provider/Supplier Representative who signed the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420844.
Findings
No deficiencies related to the allegations in Complaint IN00420844 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00420844 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 35
Census total residents: 35
Census Medicare residents: 1
Census Medicaid residents: 27
Census other payor residents: 7
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Sep 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417679.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00417679 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 35
Total Census: 35
Census Payor Type: 35
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Jul 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413562, IN00413583, and IN00413303.
Findings
No deficiencies related to the allegations were cited for any of the three complaints. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigations.
Complaint Details
Complaints IN00413562, IN00413583, and IN00413303 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 35
Census Payor Type Medicaid: 34
Census Payor Type Other: 1
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411307.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00411307 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 33
Other Payor Residents: 1
Inspection Report
Complaint Investigation
Census: 35
Capacity: 35
Deficiencies: 0
Jun 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00405009 and IN00407737.
Findings
No deficiencies were cited related to the allegations in both complaints. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00405009 - No deficiencies were cited related to the allegations. Complaint IN00407737 - No deficiencies were cited related to the allegations.
Report Facts
Census SNF/NF beds: 35
Census Payor Type Medicaid: 34
Census Payor Type Medicare: 0
Census Payor Type Other: 1
Inspection Report
Follow-Up
Census: 35
Capacity: 37
Deficiencies: 0
Jun 5, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Recertification and State Licensure Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/20/23.
Findings
At this PSR survey, Core of Bedford was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR Subpart 483.73, and with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).
Report Facts
Certified beds: 37
Census: 35
Inspection Report
Annual Inspection
Deficiencies: 0
May 22, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on March 17, 2023.
Findings
Core of Bedford was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 34
Capacity: 37
Deficiencies: 5
Apr 20, 2023
Visit Reason
An Emergency Preparedness Recertification and State Licensure Survey and a Life Safety Code Recertification were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements due to missing documentation for monthly generator load testing for seven of the last 12 months. Additionally, battery-operated smoke detectors in resident rooms were over 10 years old and lacked complete preventative maintenance documentation. The kitchen range hood exhaust system was not properly maintained, and fire drills were not conducted at unexpected times. Weekly generator inspection records were incomplete.
Severity Breakdown
SS=F: 3
SS=D: 1
SS=C: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing documentation for monthly generator load testing for seven of the last 12 months. | SS=F |
| Battery-operated smoke alarms in resident rooms were more than 10 years old and not properly maintained or documented. | SS=F |
| Failed to maintain kitchen range hood exhaust system in proper working order; fan was unhinged. | SS=D |
| Failed to conduct quarterly fire drills on unexpected days and at unexpected times under varying conditions. | SS=C |
| Failed to maintain complete written records of weekly generator inspections for 7 of 52 weeks. | SS=F |
Report Facts
Certified beds: 37
Census: 34
Missing monthly generator load testing documentation: 7
Missing weekly generator inspection records: 7
Quarterly fire drills conducted near end of month: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jordan | Administrator | Interviewed regarding generator load testing documentation and other findings |
| Maintenance Director | Interviewed regarding smoke detector maintenance and generator testing |
Inspection Report
Renewal
Census: 34
Capacity: 34
Deficiencies: 5
Mar 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 14 to 17, 2023.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with colostomies and positioning needs, inadequate pressure ulcer care and documentation, failure to implement infection control measures including a water management program and glove use during blood glucose checks, and failure to provide adequate room size per resident in multiple occupancy rooms.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for a resident with a colostomy. | SS=D |
| Failed to provide services to maintain highest practicable quality of care for a resident's positioning needs. | SS=D |
| Failed to provide services for pressure ulcer care including wound care referral and weekly wound assessments. | SS=D |
| Failed to implement infection control measures including water management program and glove use during blood glucose monitoring. | SS=F |
| Failed to provide at least 80 square feet per resident in multiple occupancy rooms (Rooms 3, 6, and 8). | SS=D |
Report Facts
Census: 34
Total Capacity: 34
Residents with colostomy care deficiency: 2
Residents affected by positioning deficiency: 1
Residents affected by pressure ulcer deficiency: 1
Residents affected by infection control deficiency: 34
Rooms with inadequate square footage: 3
Room sizes (sq ft per resident): 76
Room size (sq ft per resident): 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan M Jordan | Director of Nursing | Interviewed regarding care plan deficiencies and quality assurance |
| RN 1 | Registered Nurse | Observed not wearing gloves during blood glucose check |
| Administrator | Provided water management binder and room size certification information | |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident colostomy care |
| CNA 4 | Certified Nursing Assistant | Interviewed about positioning assistance for resident |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394076.
Findings
The complaint IN00394076 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394076 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census: 34
Total Capacity: 34
Medicaid Residents: 28
Other Residents: 6
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391779.
Findings
The complaint IN00391779 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00391779 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 33
Census Payor Type Medicaid: 28
Census Payor Type Other: 5
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