Inspection Reports for Bridgetown Nursing and Rehabilitation
4307 Bridgetown Rd, Cincinnati, OH 45211, United States, OH, 45211
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
41 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 13
Sep 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's environment, resident care, and compliance with regulations.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and sanitary environment, incomplete resident assessments, failure to provide required notifications, incomplete care plans, inadequate infection control practices, poor food quality and safety, lack of pest control, and staffing issues related to the Director of Nursing and staff training.
Complaint Details
The complaint investigation was triggered by concerns about the facility's environment, resident care, infection control, and food safety as identified in Complaint Number 1348503.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide a clean and sanitary homelike environment affecting residents' rooms and bathrooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bed hold notification to a resident upon discharge to the hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident assessments were completed in a timely manner for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly assess a resident's PASARR screening for mental health diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement complete and accurate comprehensive care plans for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care conferences and revise care plans as needed for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents wore physician ordered splint devices and document refusals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the Director of Nursing was effectively overseeing nursing services and timely completion of MDS assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete annual performance evaluations for Certified Nurse Aides. | Level of Harm - Potential for minimal harm |
| Failed to provide meals that were palatable, attractive, and served at safe and appetizing temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain, store, prepare, and serve food in a sanitary manner, including pest infestation and unsanitary kitchen conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an effective pest control program for the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff doffed PPE appropriately, perform hand hygiene, and provide proper PPE disposal for residents in Enhanced Barrier Precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 41
Residents affected: 2
Residents affected: 1
Residents affected: 17
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 17
Residents affected: 41
Residents affected: 3
Dishwasher temperature: 165
Dishwasher temperature: 145
Dishwasher temperature: 175
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #147 | Certified Nurse Aide | Confirmed environmental cleanliness issues and food service observations |
| RN #112 | Director of Nursing / MDS Nurse | Confirmed multiple late MDS assessments and staffing issues |
| Administrator in Training #102 | Administrator in Training | Confirmed lack of bed hold notifications and kitchen sanitation issues |
| LPN #121 | Licensed Practical Nurse | Verified resident splint device not worn and lack of documentation |
| Kitchen Consultant #500 | Kitchen Consultant | Tested food temperatures and confirmed unappetizing food |
| CNA #129 | Certified Nurse Aide | Observed improper PPE doffing and disposal |
| CNA #145 | Certified Nurse Aide | Observed improper PPE doffing and disposal |
| Social Services #108 | Social Services | Confirmed lack of care conferences documentation |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Sep 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's legal representative of a significant change in the resident's care and treatment.
Findings
The facility failed to notify the legal representative of Resident #34 about the change in anticoagulant medication from Coumadin to Eliquis on 06/13/24, despite policy requiring notification of such changes. Interviews and record reviews confirmed the delay in notification until approximately 07/11/24.
Complaint Details
The complaint investigation found that the facility did not notify the legal representative of Resident #34 about the medication change from Coumadin to Eliquis until nearly a month after the change was made, which is against facility policy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the resident's legal representative of a significant change in the resident's care and treatment regarding medication change. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #403 | Licensed Practical Nurse | Interviewed regarding medication change and notification failure |
| Nurse Practitioner #1001 | Nurse Practitioner | Ordered medication change from Warfarin to Eliquis |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Apr 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to complete comprehensive care plans and to follow infection control procedures during wound care dressing changes.
Findings
The facility failed to develop and implement complete care plans addressing residents' skin integrity, affecting two residents. Additionally, the facility did not follow proper infection prevention and control procedures during dressing changes, specifically failing to perform hand hygiene and change gloves appropriately, affecting one resident.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00152359.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete comprehensive care plans addressing residents' skin integrity and pressure injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control procedures during dressing changes, including lack of hand hygiene and glove changes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents reviewed for care plans: 4
Residents reviewed for wound care: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Physician #53 | Verified Resident #14 had a stage two pressure ulcer | |
| Minimum Data Set (MDS) Coordinator #51 | Verified care plans should address residents' skin integrity | |
| Licensed Practical Nurse (LPN) #54 | Observed failing to perform hand hygiene and change gloves during wound care | |
| State Tested Nursing Assistant (STNA) #55 | Observed during wound care dressing change |
Inspection Report
Routine
Census: 38
Deficiencies: 4
May 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of hospital transfers and bed hold policies, menu accuracy and notification, and food storage and sanitation practices.
Findings
The facility failed to notify the Ombudsman and residents or their representatives timely about hospital transfers and bed hold notices for two residents. The facility also failed to notify residents in advance of menu changes and served meals inconsistent with posted menus. Additionally, food storage and kitchen sanitation practices were inadequate, with uncovered, unlabeled, and undated food items and dirty kitchen equipment.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide timely notification to the resident, resident representative, and Ombudsman before transfer or discharge, including appeal rights. | Level of Harm - Potential for minimal harm |
| Failed to notify the resident or 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. | Level of Harm - Potential for minimal harm |
| Failed to notify residents in advance of menu changes; menus posted were not current and residents were served meals different from the posted menu. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored properly to prevent food borne illness and failed to maintain kitchen equipment and fixtures in a clean and sanitary manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 38
Residents affected: 2
Residents affected: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager #40 | Dietary Manager | Interviewed regarding menu changes, food ordering errors, and kitchen sanitation |
| Registered Dietitian #300 | Registered Dietitian | Interviewed regarding menu changes and residents' dislike of veal |
| Dietary Aide #2 | Dietary Aide | Verified food storage deficiencies during observation |
| Dietary Aide #26 | Dietary Aide | Observed bringing cooked hamburger patty with thermometer for temperature check |
| Administrator | Interviewed regarding failure to notify Ombudsman and bed hold notices |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 10
Apr 11, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including insufficient surety bond coverage for resident funds, failure to timely notify physicians of significant changes in resident status, untimely provision of Medicare non-coverage notices, privacy violations, inadequate care and assistance with activities of daily living, failure to provide care consistent with physician orders, failure to address significant weight loss timely, and failure to provide medically-related social services to resolve roommate issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to ensure surety bond was sufficient to cover resident funds totaling $10,879.33 while bond limit was $10,000. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely notify resident's physician of significant change in physical status related to weight loss for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide Notice of Medicare Non-Coverage timely to two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure privacy for a resident when staff entered room without knocking. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain a homelike environment for a resident whose clothing was piled on floor and wardrobe. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide written discharge notice including reasons and appeal rights to resident and representative prior to hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide daily care to a dependent resident, leaving resident soiled and in unsanitary conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide care consistent with physician orders for oxygen therapy and elastic stockings. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely address significant weight loss for two residents, including failure to notify physician and implement interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide medically-related social services to assist residents in resolving roommate issues impacting psychosocial well-being. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 26
Surety bond limit: 10000
Resident funds total balance: 10879.33
Census: 55
Weight loss: 21
Weight loss percentage: 15.2
Weight loss percentage: 8.61
Weight loss percentage: 14.24
Weight loss percentage: 6.7
Weight loss percentage: 9.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #92 | Licensed Practical Nurse | Verified resident #15 weight loss and lack of physician notification |
| RD #50 | Registered Dietitian | Reported not being notified of resident #15's weight loss and described nutritional interventions |
| STNA #115 | State Tested Nurse Aide | Observed feeding resident #15 and noted frozen nutritional supplement missing from tray |
| Administrator | Acknowledged surety bond limit and verified resident #15's weight loss as significant change | |
| SSD #58 | Social Service Designee | Verified untimely Medicare non-coverage notices and discussed roommate issues |
| DON | Director of Nursing | Verified observations of resident care deficiencies and lack of timely reweigh for resident #14 |
| LPN #52 | Licensed Practical Nurse | Verified oxygen order missing for resident #35 and failure to apply elastic stockings for resident #4 |
| LPN #79 | Licensed Practical Nurse | Assisted resident #30 after STNA left resident unattended |
| STNA #20 | State Tested Nurse Aide | Failed to provide care to resident #30 |
| STNA #91 | State Tested Nurse Aide | Reported on roommate interactions between residents #13 and #39 |
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