Inspection Reports for
Bridgewater Center for Rehabilitation & Nursing, LLC
159-163 Front Street, Binghamton, NY, 13905
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
278% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 25, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, providing necessary assistance with activities of daily living including showering, and ensuring appropriate treatment and care according to orders and resident preferences. Issues included unclean resident rooms and common areas, missed showers for residents requiring assistance, and medication and treatment administration errors including missed or late tube feedings and medications.
Deficiencies (3)
F 0584: The facility failed to ensure a safe, clean, comfortable, and homelike environment for multiple resident units. Observations included urine odor, unclean floors, food debris, and brown splatter on toilets and surfaces.
F 0677: The facility did not provide necessary assistance with activities of daily living, specifically showering, for residents #46 and #99 as planned and scheduled.
F 0684: The facility failed to provide treatment and care according to orders and resident preferences. Resident #236 had medications and tube feedings administered late or not at all, with documentation errors. Resident #99 did not receive medicated shampoo as ordered, and certified nurse aides administered it instead of licensed staff.
Report Facts
Residents units reviewed: 8
Residents reviewed for ADL assistance: 11
Residents reviewed for treatment and care: 2
Missed showers documented: 3
Missed shower date: 1
Tube feeding times ordered: 4
Medications scheduled for Resident #236 at 8:00 AM: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #45 | Certified Nurse Aide | Named in failure to assist Resident #46 with scheduled showers |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in medication and tube feeding administration errors for Resident #236 |
| Licensed Practical Nurse #17 | Licensed Practical Nurse | Named in medication and tube feeding administration for Resident #236 |
| Certified Nurse Aide #50 | Certified Nurse Aide | Named in failure to provide scheduled shower to Resident #99 and use of medicated shampoo |
| Registered Nurse Unit Manager #13 | Registered Nurse Unit Manager | Named in oversight of shower scheduling and medication administration |
| Director of Nursing | Director of Nursing | Named in interviews regarding shower scheduling and medication administration policies |
| Nurse Practitioner #28 | Nurse Practitioner | Named in orders and notification regarding missed tube feedings for Resident #236 |
| Nurse Practitioner #49 | Nurse Practitioner | Named in orders and notification regarding missed medicated shampoo for Resident #99 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Feb 25, 2025
Visit Reason
Recertification and abbreviated surveys conducted from 2/19/2025 to 2/25/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility had multiple deficiencies including failure to maintain a safe, clean, and homelike environment; inadequate assistance with activities of daily living such as showering; medication administration errors including missed and late doses; failure to provide appropriate colostomy care; inadequate dialysis care; lack of person-centered mental health interventions; medication storage and labeling issues; food service problems including improper food temperatures and unclean kitchen conditions; and lapses in infection prevention and control practices.
Deficiencies (12)
F 0584: The facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 8 resident units. Observations included strong urine odor, unclean floors, food debris, and continuously running sinks.
F 0677: Residents #46 and #99 were not assisted with showering as planned, missing multiple scheduled showers despite care instructions.
F 0684: Resident #236 had multiple medication administration errors including late and missed tube feedings, medications signed as given prior to administration, and treatments not completed as documented.
F 0684: Resident #99 did not receive ordered medicated shampoo during showers; certified nurse aides administered shampoo instead of licensed staff, and provider was not notified of missed doses.
F 0691: Resident #745 with a colostomy did not have appropriate care plans or orders; staff were unaware of colostomy care needs; colostomy bag was often missing or leaking and not emptied timely.
F 0698: Resident #257 on dialysis did not consistently have vital signs assessed pre- and post-dialysis; dialysis communication logs were not reviewed or signed by facility nurses; provider was not notified of missed or incomplete dialysis treatments.
F 0745: Resident #153 with extensive mental health history lacked person-centered psychiatric care plan; behavioral interventions and safety plans were not implemented; resident hid butter knives under mattress without follow-up.
F 0760: Resident #744 missed 10 doses of Abilify over 4 days due to medication unavailability; provider was not notified of missed doses and no nursing assessment was documented.
F 0761: The 2B East medication cart contained multiple opened undated insulin vials and pens, including expired insulin; vaccines were stored unsecured on top of the medication cart.
F 0804: Food and drink were not served at safe or appetizing temperatures during lunch meals on 2/21/2025 and 2/24/2025; food was bland, cold, or difficult to cut; residents reported food was unappetizing.
F 0812: Main kitchen and Unit 2A had multiple sanitation issues including food stored on floors, expired foods, unclean surfaces, hair nets not worn by staff, and presence of fruit flies and mouse traps.
F 0880: Resident #226 on enhanced barrier precautions had tube feeding administered without gown and gloves; Resident #49 on contact precautions had care provided without proper PPE and hand hygiene; X-ray technician did not wear PPE during procedure.
Report Facts
Missed doses of Abilify: 10
Temperature of fish: 125
Temperature of milk: 53
Temperature of apple juice: 58
Temperature of ginger ale: 53
Temperature of cottage cheese: 54.1
Temperature of coffee: 133.9
Temperature of peaches and mandarin oranges: 52.5
Temperature of chocolate milk: 53.2
Milk cooler temperature: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 9 | Certified Nurse Aide | Did not wear gown or perform hand hygiene when providing care to Resident #49 on contact precautions. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Administered tube feeding to Resident #226 without wearing gown as required by enhanced barrier precautions. |
| Licensed Practical Nurse 14 | Licensed Practical Nurse | Reported pharmacy deliveries and medication refill process; involved in medication administration observations. |
| Registered Nurse Unit Manager 13 | Registered Nurse Unit Manager | Discussed medication storage and insulin labeling; vaccine handling; dialysis communication; and medication notification procedures. |
| Dietary Supervisor 26 | Dietary Supervisor | Discussed food temperature standards and kitchen cleaning procedures. |
| Food Service Director | Food Service Director | Provided information on kitchen cleaning, food storage, and food temperature requirements. |
| Infection Control Preventionist 5 | Infection Control Preventionist | Discussed infection control policies and PPE requirements for residents on precautions. |
| Nurse Practitioner 12 | Nurse Practitioner | Discussed expectations for notification of missed dialysis and medication doses. |
| Nurse Practitioner 28 | Nurse Practitioner | Discussed expectations for notification of missed tube feedings and medication administration. |
| Certified Nurse Aide 32 | Certified Nurse Aide | Reported lack of knowledge of Resident #745 colostomy and failure to provide colostomy care. |
| Social Worker 54 | Social Worker | Discussed lack of person-centered psychiatric care plan and behavioral interventions for Resident #153. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 20
Date: Feb 25, 2025
Visit Reason
Inspection identified 12 standard health citations and 8 life safety code citations, mostly Level 2 severity, all corrected by mid-2025.
Findings
Inspection identified 12 standard health citations and 8 life safety code citations, mostly Level 2 severity, all corrected by mid-2025.
Deficiencies (20)
ADL care provided for dependent residents
Colostomy, urostomy, or ileostomy care
Dialysis
Food procurement,store/prepare/serve-sanitary
Infection control
Infection prevention & control
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Provision of medically related social service
Quality of care
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Building construction type and height
Discharge from exits
Hazardous areas - enclosure
Multiple occupancies - construction type
Number of exits - corridors
Smoking regulations
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements for nursing home care, infection control, and facility environment.
Findings
The facility failed to ensure residents were treated with dignity and respect, maintain a safe and clean environment, and implement an effective infection prevention and control program. Specific issues included failure to honor bathing preferences, uncovered urinary catheter bags, unclean and disrepair conditions in multiple resident areas, improper use of PPE including N95 masks by staff, and inadequate wound care practices.
Deficiencies (3)
F 0550: The facility failed to honor residents' dignity and bathing preferences for 2 residents. Resident #24 did not receive their preferred weekly shower, and Resident #165's urinary catheter bag was uncovered and visible.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment. Multiple resident rooms, common areas, and a resident chair were found unclean or in disrepair, including damaged walls, ceilings, fixtures, and furniture.
F 0880: The facility failed to implement an effective infection prevention and control program. Staff improperly wore N95 masks, increasing COVID-19 transmission risk, and wound care procedures for Resident #197 did not follow infection control standards, including improper storage of supplies and inadequate hand hygiene.
Report Facts
Residents affected: 2
Residents affected: 15
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #32 | Certified Nurse Aide | Named in bathing preference and improper mask wearing findings |
| LPN #33 | Licensed Practical Nurse | Named in improper mask wearing and infection control findings |
| Unit Helper #34 | Named in improper mask wearing findings | |
| Dietary Supervisor #38 | Dietary Supervisor | Named in improper mask wearing findings |
| LPN #39 | Licensed Practical Nurse | Named in wound care infection control findings |
| RN Manager #7 | Registered Nurse Manager | Named in wound care and infection control findings |
| RN Educator #37 | Registered Nurse Educator | Named in infection control education and mask wearing findings |
| Assistant Director of Nursing (ADON) #3 | Assistant Director of Nursing | Named in infection control and mask wearing findings |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements and quality of care standards at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences and dignity, unsafe and unclean environment conditions, significant medication errors related to administration routes, expired medications storage, improper infection prevention and control practices including improper N95 mask use, and inadequate wound care infection control.
Deficiencies (5)
F 0550: The facility failed to ensure residents were treated with dignity and respect, including honoring bathing preferences and covering urinary catheter bags for privacy.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment, with multiple resident rooms, common areas, and devices found unclean or in disrepair.
F 0760: The facility failed to ensure residents were free from significant medication errors, including administering medications by mouth to a resident who was NPO and required tube feeding.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, with expired medications and unlabeled insulin pens found in medication carts and rooms.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper N95 mask use by staff on COVID-19 units and inadequate infection control during wound care.
Report Facts
Residents affected: 2
Resident rooms unclean or in disrepair: 15
Resident common areas unclean or in disrepair: 10
Medication carts with expired medications: 2
Medication storage rooms with expired medications: 2
Residents affected by medication error: 1
Staff members with improper N95 mask use: 4
Residents affected by infection control deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #25 | Registered Nurse | Administered medications via gastrostomy tube despite physician orders indicating by mouth |
| LPN #27 | Licensed Practical Nurse | Discussed medication administration route and need to clarify orders |
| RN Unit Manager #28 | Registered Nurse Unit Manager | Discussed medication administration errors and order clarifications |
| Pharmacy Consultant #26 | Pharmacy Consultant | Recommended clarification of medication orders for Resident #250 |
| SLP #24 | Speech Language Pathologist | Recommended continued NPO and tube feeding for Resident #250 |
| NP #29 | Nurse Practitioner | Provided verbal orders and confirmed medication administration route errors |
| LPN #4 | Licensed Practical Nurse | Observed with expired medications in medication cart |
| LPN #5 | Licensed Practical Nurse | Observed with expired medications in medication cart and medication room |
| LPN #6 | Licensed Practical Nurse | Observed expired vaccine vial in medication room refrigerator |
| RN Unit Manager #7 | Registered Nurse Unit Manager | Discussed medication expiration checks and wound care |
| ADON #3 | Assistant Director of Nursing | Discussed medication expiration checks and mask wearing expectations |
| CNA #32 | Certified Nurse Aide | Observed wearing surgical mask instead of N95 on COVID-19 unit |
| LPN #33 | Licensed Practical Nurse | Observed improper N95 mask use and discussed mask wearing education |
| Unit Helper #34 | Unit Helper | Observed improper N95 mask use and discussed mask wearing education |
| Dietary Supervisor #38 | Dietary Supervisor | Observed improper mask wearing on COVID-19 unit |
| LPN #39 | Licensed Practical Nurse | Observed performing wound care with infection control deficiencies |
| RN Manager #7 | Registered Nurse Manager | Discussed wound care and infection control practices |
| Wound Care RN #40 | Wound Care Registered Nurse | Discussed wound care supply storage and infection control |
| RN Educator #37 | Registered Nurse Educator | Discussed PPE and N95 mask education and expectations |
| LPN #35 | Licensed Practical Nurse | Discussed proper N95 mask wearing and education |
| RN Infection Preventionist | Registered Nurse Infection Preventionist | Discussed infection control policies and mask wearing requirements |
| Director of Nursing | Director of Nursing | Discussed medication expiration and storage policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Mar 28, 2023
Visit Reason
Inspection identified 5 standard health citations and 5 life safety code citations, mostly Level 2 severity, all corrected by mid-2023 except one life safety code citation with no correction date.
Findings
Inspection identified 5 standard health citations and 5 life safety code citations, mostly Level 2 severity, all corrected by mid-2023 except one life safety code citation with no correction date.
Deficiencies (10)
Infection prevention & control
Label/store drugs and biologicals
Resident rights/exercise of rights
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Multiple occupancies - construction type
Rubbish chutes, incinerators, and laundry chu
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 2, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, incomplete care planning, inadequate treatment and monitoring of residents, failure to provide appropriate feeding assistance, and failure to maintain residents' range of motion devices. Deficiencies were noted for several residents with minimal harm and few residents affected.
Deficiencies (5)
F 0584: The facility did not ensure a safe, clean, and homelike environment for Resident #34, as the resident's room contained a non-functioning clock and two outdated calendars visible for four days.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #127, as the Ethics Committee review was requested but not conducted for six months.
F 0684: Resident #212 did not receive appropriate treatment and care according to orders and preferences, specifically insulin was administered before meals that the resident did not eat, with no documented monitoring for hypoglycemia.
F 0688: Resident #179 with limited range of motion was observed without prescribed bilateral palm grips, which were discontinued after hospitalization and not reordered upon return.
F 0692: Resident #212 was not provided adequate meal assistance and experienced significant weight loss, with multiple meals not consumed or documented and inconsistent monitoring of nutritional intake.
Report Facts
Deficiencies cited: 5
Weight measurements: 172.6
Weight measurements: 199.6
Weight measurements: 184.5
Insulin doses: 4
Insulin doses: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work #15 | Director of Social Work | Stated the Ethics Committee would meet within one week of request and was responsible for setting up the meeting for Resident #127. |
| Activities Director | Activities Director | Reported instructing staff to check clocks and calendars and expected corrections for Resident #34. |
| Nurse Practitioner | Nurse Practitioner | Documented care and treatment plans for Resident #127 and Resident #212, including Ethics Committee consult and insulin management. |
| Registered Nurse #12 | Unit Manager | Reported expectations for feeding assistance and documentation for Resident #212 and care for Resident #179. |
| Physical Therapist #13 | Director of Rehabilitation | Reported on Resident #179's need for palm grips and brought new splints after assessment. |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Assigned to Resident #212 on 9/30/20 and described feeding assistance and documentation practices. |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Described feeding assistance responsibilities and denied removing Resident #212's lunch tray. |
| Registered Dietitian #14 | Registered Dietitian | Reported on Resident #212's nutritional status, feeding needs, and weight monitoring. |
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