Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Bedford during CMS and state inspections, most recent first.
Surveyors found that two shower rooms were not maintained according to infection control standards, including soiled linens and resident clothing left on the floor, unlabeled personal care items such as shampoo and combs with hair present, and an unused brief stored on a sink. In another shower room, surveyors observed a pile of hair on the shower floor, missing tiles that prevented surfaces from being fully cleanable, unlabeled shampoo and body cleanser bottles, and an uncovered toilet plunger resting on the floor beside the toilet. The DON confirmed that these conditions did not meet infection control practices and that resident items should be labeled and soiled linens kept off the floor.
Two residents with significant medical conditions and documented need for assistance with bathing did not consistently receive their scheduled twice-weekly showers or baths. One resident with dementia and multiple chronic conditions was scheduled for showers on specific days during day shift but, according to point of care task (PCT) records, often received only one shower per week over several weeks. Another cognitively intact resident with post-stroke paralysis and other comorbidities was scheduled for evening shift showers twice weekly, yet PCT documentation showed entire weeks with no showers or only one provided, with limited refusal documentation. Both residents reported they did not always receive twice-weekly bathing, and the DON confirmed the missed showers upon review of the records and could not explain the failures.
A facility failed to report and investigate an incident where a resident with behavioral issues struck another resident on her recently operated arm, causing pain. The incident was not documented properly, and the investigation was incomplete, with no report to the state. The care plan for the aggressive resident was not updated following the incident, highlighting a lapse in protocol adherence.
A facility failed to investigate and document an incident where a resident with a recent fracture was reportedly hit by another resident with behavioral issues. The incident was not properly documented or reported to the state, and the care plan for the resident with behavioral issues was not updated to prevent future occurrences. This lack of thorough investigation and follow-up highlights the facility's inadequate response to the incident.
The facility's insufficient staffing in Dietary Services affected 107 residents, causing delays in meal preparation and delivery. Observations revealed that additional staff from another facility were assisting with meal services, and the Dietary Manager confirmed understaffing. Residents reported receiving meals significantly later than scheduled, with some meals arriving hours late. The facility occasionally ordered pizza from an outside vendor to compensate for the delays.
The facility failed to maintain cleanliness and proper sanitation in the food service area, affecting 107 residents. Observations revealed soiled kitchen flooring, inadequate dish machine sanitization, and improper food storage practices. Equipment such as the Juice Machine and ovens were found with food residue, and the ventilation grill was heavily soiled. Additionally, the kitchen floor was dirty, and the dry storage room had improperly stored items.
The facility failed to provide palatable food at safe temperatures, affecting 107 residents. Observations showed food was often served below required temperatures, and residents reported meals as cold and unappetizing. Food was transported in non-insulated carts, contributing to the issue, and some meals did not meet dietary preferences or restrictions.
The facility failed to maintain cleanliness and proper maintenance, affecting 107 residents. Observations revealed soiled fans, leaking fixtures, stained ceiling tiles, and damaged surfaces in various areas, including resident rooms and common areas. The facility's policies on housekeeping and maintenance were not effectively implemented, as evidenced by the lack of specific entries in the work order system for the observed issues.
A facility failed to ensure complete advance directive documentation for a resident with complex medical conditions. The resident's Code Status document, signed by a guardian, lacked a date for one witness's signature and was missing a second witness's signature. The social worker responsible could not explain the incomplete documentation, which did not comply with the facility's policy requiring two witness signatures.
A facility failed to complete a PASARR for a resident with mental health diagnoses after the 30-day exemption period and did not notify the state mental health authority. The resident was marked as a hospital exemption discharge, but no updated PASARR or referral was made after the exemption lapsed, as confirmed by the social worker.
A facility failed to properly communicate and document hospice services for a resident with severe cognitive impairment and multiple diagnoses, leading to a lack of coordinated care. Despite a physician's order for hospice services, the resident's plan of care and Kardex lacked details on the specific services and their frequency. Interviews with staff revealed a lack of clarity and documentation, and the hospice agency's absence from care conferences further highlighted the deficiency.
Inadequate Infection Control Practices in Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the condition and use of two resident shower rooms. In the shower room across from a specified resident room, observations showed soiled linen on the floor next to a cabinet, three empty and unlabeled shampoo bottles on the shower assist bar, an unused brief placed on the back of the sink, and a black comb with hair present that was not labeled with any resident’s name and was stored on top of the paper dispenser. On a subsequent observation of the same shower room with the DON, surveyors again noted soiled resident clothing and towels on the floor, a soiled towel on the shower stretcher, an unused brief on the back of the sink, and the same unlabeled black comb with hair on top of the paper dispenser. The DON stated that soiled linen and resident clothing should not be placed on the floor, that resident personal items should be labeled, and that these conditions did not meet infection control standards of practice. In the shower room across from the coffee shop, surveyors observed a hand-sized pile of dark-colored hair on the shower floor near the drain, missing corner tile in the shower, and missing tile near the toilet paper dispenser. On a later observation of this same shower room with the DON, surveyors found a used bottle of shampoo and a bottle of body cleanser on the assist bar without resident names, an uncovered toilet bowl plunger resting directly on the floor beside the toilet, and the same areas of missing tile. The DON explained that the missing tile prevented the shower and area near the toilet from having a cleanable surface and that the toilet plunger should have been placed in a bag rather than sitting on the floor.
Failure to Provide Scheduled Showers/Baths to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or baths to dependent residents in accordance with their assessed needs and shower schedules. One resident was admitted with multiple medical conditions including aortic valve stenosis, osteoporosis, right foot drop, depression, anxiety, dementia, and other chronic issues. Her MDS dated 12/20/2025 showed moderate cognitive impairment (BIMS 11/15) and a need for partial/moderate assistance with showering/bathing. Facility shower schedules and point of care task (PCT) documentation indicated she was to receive showers every Monday and Thursday on day shift. However, PCT records showed that during multiple weeks in November 2025, December 2025, and January 2026, she received only one shower per week instead of two. The resident’s family member reported she was not receiving showers twice weekly, and the resident herself stated she did not always receive a bath/shower twice a week, though she could not specify the days or times. Another resident, admitted with right-sided paralysis following a stroke, bilateral knee osteoarthritis, depression, abnormal posture, right hand contracture, hypertension, hyperlipidemia, cocaine abuse, nicotine dependence, and chronic kidney disease, was cognitively intact per an MDS BIMS score of 15/15 dated 01/05/2026. The same MDS indicated he required substantial/maximal assistance with showering/bathing. The facility’s shower schedule and PCT documentation showed he was to receive showers every Monday and Thursday on evening shift. Review of his PCT records revealed missed showers during several weeks in November 2025, December 2025, and January 2026, including weeks where no showers were documented or only one of the two scheduled showers was provided, with only a single refusal documented for one missed shower. During interview, this resident reported he did not always receive a bath/shower twice per week. The DON confirmed, after reviewing PCT documentation, that both residents had not received showers as scheduled and could not explain why showers were not completed twice weekly as planned.
Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act 42CFR483. This deficiency was identified during a review of an incident involving two residents, where one resident, with a history of behavioral issues, struck another resident on her recently operated left arm. The incident was not reported to the state, and the investigation was incomplete, with several areas left blank and lacking documentation of the incident's details and outcomes. The affected resident, who had a moderate cognitive impairment and required assistance with daily activities, reported being hit by another resident while in her wheelchair. The incident caused her pain, and an X-ray was ordered due to the recent surgery on her left arm. Despite the resident's complaint and the subsequent medical assessment, the incident was not properly documented in the nursing progress notes, and the investigation was not completed or reported to the state authorities. The resident who struck the other had a history of behavioral problems, including aggression towards staff and other residents. His care plan noted these issues, but it was not updated following the incident. The facility's failure to document the incident properly, investigate it thoroughly, and report it to the state reflects a significant lapse in adhering to required protocols for handling and reporting suspected abuse or neglect within the facility.
Failure to Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, resulting in known allegations of abuse going uninvestigated and the potential for further abuse without intervention or protection. One resident, who had a history of falling and a recent fracture, reported being hit on her injured arm by another resident. Despite the resident's complaint of pain and the incident being reported to staff, the incident was not properly documented or reported to the state, and the investigation was incomplete. The incident report completed by an LPN did not include critical details such as the results of an X-ray ordered for the injured resident's shoulder. Interviews with staff revealed inconsistencies in the handling of the incident, with some staff members acknowledging the need for new interventions to prevent recurrence, while others did not document the incident in the resident's care plan. The facility's failure to document and report the incident properly indicates a lack of thorough investigation and follow-up. The resident who allegedly caused the incident had a history of behavioral issues, including aggression towards staff and other residents. Despite this, the care plan for the resident was not updated following the incident, nor were new interventions implemented to address the behavior. The lack of documentation and failure to update the care plan for the resident with behavioral issues further highlights the facility's inadequate response to the incident and the potential risk to other residents.
Insufficient Dietary Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient staffing in the Dietary Services department, affecting 107 residents and leading to delays in meal preparation and delivery. During a comprehensive tour of the food service area, it was observed that additional staff from another regional corporate facility were assisting with breakfast meal preparation and delivery. The Dietary Manager confirmed that the facility was understaffed, missing one dietary staff member and two dietary aides, which contributed to the delays. Several residents reported receiving their meals significantly later than scheduled. One resident, who was cognitively intact, reported receiving breakfast after 10:00 AM, despite it being scheduled for 8:30 AM. Another resident, also cognitively intact, reported frequent delays in meal service, with breakfast sometimes arriving as late as 11:00 AM and lunch at 2:30 PM. Additionally, it was noted that the facility occasionally resorted to ordering pizza from an outside vendor to provide meals to residents, indicating a persistent issue with meal service timeliness.
Deficiencies in Food Service Sanitation and Equipment Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the food service area, affecting 107 residents. Observations revealed that the flooring surfaces in the kitchen were soiled with accumulated dust, dirt, and grease. The wall/floor junctures, corners, and entrance door frame cavities were also observed to be dirty. Additionally, the emergency eye wash station receptacle and the entrance door exterior surface between the Main Dining Room and Food Production Kitchen were found to be soiled with dust and grime. The mechanical dish machine was observed to have a wash temperature gauge reading of 136 degrees Fahrenheit and a final rinse temperature gauge reading of 176 degrees Fahrenheit, with a PSI gauge reading of 0 psi during the final rinse cycle. Although the thermal verification tape indicated proper sanitization, the flow pressure did not meet the required standards. Furthermore, a water supply valve was leaking above the ice machine in-line filter, and the Crown steamer copper drain line connection was leaking water onto the floor near an electrical supply line. The service sink faucet was also loose-to-mount. Food storage practices were inadequate, with an open gallon of milk lacking an effective open or out date mark. The Juice Machine, South Bend convection oven, Vulcan hot box, and Amana microwave oven were all observed to be soiled with food residue. The return-air-exhaust ventilation grill was heavily soiled with dust and dirt deposits. Additionally, the kitchen floor was observed to be soiled with a black substance, and water was present under the tray line table. The walk-in freezer contained a boxed pie crust with a frozen clear substance on the outside, and the dry storage room had multiple boxes on the floor, including torte shells and open boxes of cups and napkins, with the floor visibly soiled.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide palatable food products for seven reviewed residents, affecting a total of 107 residents. Observations and interviews revealed that food was often served at temperatures below the required standards set by the 2017 FDA Model Food Code. For instance, the temperature of chicken teriyaki was recorded at 120.8 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit. Additionally, residents reported that their meals were frequently served lukewarm or cold, with some expressing dissatisfaction with the taste and quality of the food. The report highlights specific instances where food was transported in non-insulated carts, which likely contributed to the inadequate temperatures upon arrival at the residents' rooms. Residents consistently reported that their meals were not only cold but also unappetizing, with some meals not meeting dietary preferences or restrictions. For example, a resident on a mechanical soft diet received a dinner roll instead of a spring roll, and another resident received bread and green vegetables despite dietary guidance to exclude these items. Interviews with residents further confirmed the issue, with several residents expressing dissatisfaction with the temperature and quality of their meals. One resident mentioned that the food was "stone cold," while another described it as "yuck." The facility's policies on food handling and tray accuracy were reviewed, revealing that there were procedures in place to ensure proper food temperatures and tray accuracy, but these were not effectively implemented, leading to the deficiencies observed.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 107 residents. During an environmental tour, several areas were found to be inadequately maintained. In the beauty shop, a desk fan was observed with accumulated dust and dirt. In the 100 Hall shower room, return-air-ventilation grills were heavily soiled, and the ambulance entrance/exit door had a worn door sweep, creating an open space. The 200 Hall restroom had a leaking commode base standpipe supply line, and the main dining room had stained ceiling tiles. The center nursing station's floor fan was also soiled. In the 300 Hall, the janitor closet's mop sink basin and return-air-exhaust ventilation grill were heavily soiled. The tub room had a leaking hot water supply handle, and the shower room's ventilation grill was soiled. Sampled resident rooms revealed various issues, including loose paper towel dispensers, soiled fans, non-functional light assemblies, and soiled bedding. Several rooms had damaged drywall surfaces, loose vinyl coving strips, and etched restroom entrance door surfaces. Additionally, some restroom hand sink basins were draining slowly. The facility's housekeeping and maintenance policies were reviewed, revealing a lack of specific entries related to the observed maintenance concerns in the Direct Supply TELS Work Orders for the last 60 days. The housekeeping policy emphasized thorough scrubbing and routine cleaning of horizontal surfaces, while the maintenance policy aimed to assure proper maintenance of the physical plant. However, the observations indicated that these policies were not effectively implemented, leading to the deficiencies noted during the survey.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for a resident who was admitted with multiple complex medical conditions, including Huntington's Disease, dementia, and epilepsy. The resident, who had a court-appointed guardian, had a Resident Code Status document that was incomplete. The document, dated January 15, 2024, was signed by the guardian but lacked the required date for one witness's signature and was missing a second witness's signature entirely. During an interview, the social worker responsible for coordinating advance directives admitted that it was her responsibility to ensure the Resident Code Status document was completed in its entirety, including signatures and dates from two witnesses. However, she could not explain why the document for this resident was incomplete. The facility's policy on advance directives required a Code Status Form to be completed by the resident and signed by two witnesses and a physician, which was not adhered to in this case.
Failure to Complete PASARR After 30-Day Exemption
Penalty
Summary
The facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed for a resident after the 30-day exemption period and did not notify the State mental health authority. The resident was admitted with diagnoses including major depressive disorder, anxiety, bipolar disorder, post-traumatic stress disorder, and schizophrenia. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The PASARR Level I screening marked the resident as a hospital exemption discharge, indicating a likely need for less than 30 days of nursing services. However, after the 30-day exemption period lapsed, the facility did not complete an updated PASARR or refer the case to the state mental health authority, as confirmed by the social worker who lacked documentation of these actions.
Deficiency in Hospice Service Coordination and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including protein-calorie malnutrition, palliative care needs, and severe cognitive impairment, was observed denying receipt of hospice services. Despite a physician's order for hospice evaluation and treatment, the resident's plan of care lacked details on the specific hospice services and their frequency. The Kardex also failed to include this information, indicating a gap in communication and documentation. Interviews with facility staff, including an LPN, Nurse Manager, and DON, revealed a lack of clarity and documentation regarding the hospice services provided to the resident. The LPN was unaware of the specific services or their frequency, and the Nurse Manager could not provide a hospice calendar or explain the absence of service details in the plan of care. Additionally, the Care Conference Minutes did not show attendance by the hospice agency, further highlighting the deficiency in coordination and communication of hospice services for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Battle Creek | 2.4 mi | — | 12 | 0 |
| The Oaks At Battle Creek | 2.6 mi | — | 0 | 0 |
| Evergreen Manor Senior Care Center | 2.7 mi | — | 19 | 0 |
| Pinnacle Care Of Battle Creek | 4.2 mi | — | 15 | 0 |
| Calhoun County Medical Care Facility | 6 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.