Inspection Reports for
Bridgewater Center for Rehabilitation & Nursing, LLC
159-163 Front Street, Binghamton, NY, 13905
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Inspection Report — Feb 25, 2025
State
Date: Feb 25, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 163 complaints about this facility; 16 led to on-site inspections. The facility received 6 citations resulting from complaints during the reporting period.
Findings
Across three inspections, the facility received a total of 31 citations, including 17 standard health citations and 14 Life Safety Code citations. One enforcement action with a $10,000 fine related to infection control was recorded during this period.
Citations (29)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents found deficient with isolated scope.
Standard Health Citation — quality of care: Colostomy, Urostomy, Or Ileostomy Care found deficient with isolated scope.
Standard Health Citation — quality of care: Dialysis care found deficient with isolated scope.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary found deficient with pattern scope.
Standard Health Citation — quality of care: Infection Control found deficient with isolated scope.
Standard Health Citation — quality of care: Infection Prevention & Control found deficient with isolated scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals found deficient with isolated scope.
Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp found deficient with pattern scope.
Standard Health Citation — quality of care: Provision Of Medically Related Social Service found deficient with isolated scope.
Standard Health Citation — quality of care: Quality Of Care found deficient with isolated scope.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors found deficient with isolated scope.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Building Construction Type And Height found deficient with widespread scope.
Life Safety Code Citation — NFPA requirements: Discharge From Exits found deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure found deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies - Construction Type found deficient with widespread scope.
Life Safety Code Citation — NFPA requirements: Number Of Exits - Corridors found deficient with widespread scope.
Life Safety Code Citation — NFPA requirements: Smoking Regulations found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures found deficient with widespread scope.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie found deficient with isolated scope.
Standard Health Citation — quality of care: Infection Prevention & Control found deficient with pattern scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals found deficient with isolated scope.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights found deficient with isolated scope.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors found deficient with isolated scope.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extens found deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste found deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies - Construction Type found deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure found deficient with isolated scope.
Report Facts
Inspections on page: 3
Total citations: 31
Complaints: 163
On-site complaint inspections: 16
Citations from complaints: 6
Enforcement actions: 1
Total fines: 10000
Inspection Report — Feb 25, 2025
Annual Inspection CMS
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.
Citations (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 — Mar 28, 2023
Annual Inspection CMS
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.
Citations (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 — Oct 2, 2020
Annual Inspection CMS
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.
Citations (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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