A list of the most recent deficiencies for The Laurels of Bedford. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-07-13 | 2023-08-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-07-13 | 2023-08-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-07-13 | 2023-08-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-13 | 2023-08-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-13 | 2023-08-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-13 | 2023-08-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-13 | 2023-08-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-07-13 | 2023-08-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-13 | 2023-08-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-13 | 2023-08-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-13 | 2023-08-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-13 | 2023-08-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-13 | 2023-08-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-08-07 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-13 | 2023-08-07 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-13 | 2023-08-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-13 | 2023-08-07 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-13 | 2023-08-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-13 | 2023-08-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-11 | 2023-08-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-06 | 2023-02-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-06 | 2023-02-23 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-06 | 2023-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-29 | 2022-10-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-05 | 2022-07-21 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-05 | 2022-07-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-01 | 2022-03-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-13 | 2021-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-13 | 2021-12-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-13 | 2021-11-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-13 | 2021-11-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-13 | 2021-11-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-10-13 | 2021-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-13 | 2021-11-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-13 | 2021-11-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-13 | 2021-11-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-13 | 2021-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-13 | 2021-11-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-13 | 2021-11-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-13 | 2021-11-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-10-13 | 2021-11-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-13 | 2021-11-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-11 | 2021-11-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-11 | 2021-11-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-11 | 2021-11-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-28 | 2021-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-20 | 2019-12-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-11-20 | 2019-12-30 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-11-20 | 2019-12-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-20 | 2019-12-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-20 | 2019-12-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-20 | 2019-12-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-20 | 2019-12-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-20 | 2019-12-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-11-20 | 2019-12-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-20 | 2019-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-20 | 2019-12-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-20 | 2019-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-18 | 2019-11-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-11-18 | 2019-11-19 | N |
