Inspection Report
Renewal
Deficiencies: 0
Jun 16, 2025
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on June 16, 2025.
Findings
Bridgewater Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459409 and IN00459328 at Bridgewater Healthcare Center.
Findings
No deficiencies related to the allegations in complaints IN00459409 and IN00459328 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00459409 and Complaint IN00459328 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 102
Total Capacity: 102
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 77
Census Payor Type Other: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint Number IN00454659 that exited on 2025-03-05.
Findings
Bridgewater Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Complaint Details
Investigation of Complaint Number IN00454659 was completed with the facility found in compliance.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 120
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Number IN00454659 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with life safety code requirements related to staff instruction on the use of the UL 300 hood fire suppression system in the kitchen. Staff failed to activate the Ansul Hood Suppression System during a recent kitchen fire, although the system was in working order.
Complaint Details
Complaint Number IN00454659 was investigated and a federal/state deficiency related to the allegation was cited at K324. The finding was acknowledged by the Director of Nursing and Maintenance Director during the interview and exit conference.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure staff were instructed in the use of the UL 300 hood system in the kitchen. | SS=E |
Report Facts
Facility capacity: 120
Census: 104
Inspection date: Mar 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding the hood system fire incident and staff training | |
| Director of Nursing | Interviewed regarding the hood system fire incident and staff training |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 0
Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448839 and IN00450302.
Findings
No deficiencies related to the allegations in complaints IN00448839 and IN00450302 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00448839 and IN00450302 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 95
Census total residents: 95
Census Medicare residents: 10
Census Medicaid residents: 71
Census other payor residents: 14
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Sep 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442883 and IN00443571.
Findings
No deficiencies related to the allegations in complaints IN00442883 and IN00443571 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00442883 and Complaint IN00443571 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census SNF/NF beds: 99
Total census: 99
Medicare census: 10
Medicaid census: 72
Other payor census: 17
Inspection Report
Re-Inspection
Census: 94
Capacity: 120
Deficiencies: 0
Sep 4, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/05/24 was performed to verify compliance with previous deficiencies.
Findings
At this PSR Life Safety Code survey, Bridgewater Healthcare Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 120
Census: 94
Inspection Report
Life Safety
Census: 92
Capacity: 120
Deficiencies: 3
Aug 5, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Life Safety from Fire and related regulations.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with delayed egress door signage, corridor width obstructions, and improper use of power strips. Corrective actions were implemented promptly and ongoing monitoring was planned.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 1 of over 6 delayed egress locks was readily accessible due to lack of proper signage indicating doors can be opened in 15 seconds. | SS=E |
| Failed to meet the clear width requirement for 1 of over 5 corridors due to unsecured tables and chairs reducing corridor width to less than 6 feet. | SS=E |
| Failed to ensure 2 of over 10 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw. | SS=E |
Report Facts
Certified beds: 120
Census: 92
Delayed egress locks: 6
Corridors observed: 5
Power strips observed: 10
Staff potentially affected: 5
Residents potentially affected: 24
Staff potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed report and present at exit conference |
| Maintenance Director | Acknowledged deficiencies during observations and exit conference |
Inspection Report
Annual Inspection
Census: 92
Capacity: 92
Deficiencies: 5
Jul 22, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 16 to July 22, 2024.
Findings
The facility was found deficient in multiple areas including respect and dignity related to personal property, development and implementation of comprehensive care plans, activities of daily living, communication for non-English speaking residents, nutrition and hydration status maintenance, and behavioral health services related to hoarding behavior.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to exercise reasonable care for the protection of a resident's personal property (Resident 16). | SS=D |
| Failed to have a comprehensive care plan for a resident with congestive heart failure (Resident 3). | SS=D |
| Failed to provide necessary care and services to maintain or improve activities of daily living including communication (Resident 91). | SS=D |
| Failed to ensure physician notification of significant weight change in a timely manner (Resident 3). | SS=D |
| Failed to identify and treat a resident's behavior symptom of hoarding (Resident 70). | SS=D |
Report Facts
Census: 92
Total Capacity: 92
Weight loss percentage: 5
Survey dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed the report |
| LPN 3 | Mentioned in communication and grievance findings related to Resident 91 and Resident 16 | |
| Head of Housekeeping 4 | Involved in investigation of missing phone holder for Resident 16 | |
| Clinical Support Nurse | Provided information on care plans and BIMS score for Resident 91 and Resident 3 | |
| Social Services Designee (SSD) | Provided information on Resident 70's hoarding behavior | |
| QMA 5 | Observed and reported hoarding behavior of Resident 70 | |
| Administrator | Provided information on Resident 91 and Resident 70 | |
| Rehab Director | Provided information on Resident 91's communication abilities |
Inspection Report
Renewal
Deficiencies: 0
Jul 22, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey.
Findings
Bridgewater Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review conducted.
Inspection Report
Complaint Investigation
Census: 92
Capacity: 92
Deficiencies: 0
May 16, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00429003, IN00429791, and IN00434022.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaints IN00429003, IN00429791, and IN00434022 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 92
Total Capacity: 92
Census Payor Type Medicare: 10
Census Payor Type Medicaid: 72
Census Payor Type Other: 10
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Jan 30, 2024
Visit Reason
This visit was for the investigation of Complaint IN00426545.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00426545 - No deficiencies related to the allegations are cited.
Report Facts
Census: 88
Total Capacity: 88
Medicare Census: 5
Medicaid Census: 69
Other Payor Census: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 25, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaints IN00421402 and IN00421407 completed on December 20, 2023.
Findings
Bridgewater Healthcare Center was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the specified complaints.
Complaint Details
Investigation of Complaints IN00421402 and IN00421407; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Jan 4, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00424975.
Findings
No deficiencies related to the allegations are cited. Bridgewater Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00424975.
Complaint Details
Complaint IN00424975 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 97
Total Capacity: 97
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 74
Census Payor Type Other: 16
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 3
Dec 18, 2023
Visit Reason
The visit was conducted for the investigation of complaints IN00421402, IN00421407, IN00422706, and IN00424361 at Bridgewater Healthcare Center.
Findings
The facility was found deficient in responding to call lights, colostomy care, and medication administration/documentation for certain residents. Some complaints were substantiated with cited deficiencies, while others had no deficiencies related to the allegations.
Complaint Details
Complaint IN00421402 had federal/state deficiencies cited at F550, F691, and F755. Complaint IN00421407 had deficiencies cited at F691. Complaints IN00422706 and IN00424361 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility staff failed to answer a call light for 1 of 1 call light observed flashing on unit 3000 (Room 3012). | SS=D |
| Facility failed to check/change a colostomy bag prior to the bag bursting, failed to follow facility protocol when changing and cleaning the resident, and failed to provide a clean brief for 1 of 1 resident reviewed colostomy care (Resident C). | SS=D |
| Facility failed to provide medications/treatments per physician's orders and failed to document reasons for omissions for 2 of 3 residents reviewed for medication administration (Residents B and C). | SS=D |
Report Facts
Census: 94
Total Capacity: 94
Medicare Census: 5
Medicaid Census: 74
Other Payor Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed as provider/supplier representative on the report |
| LPN 4 | Named in colostomy care deficiency and corrective action | |
| CNA 1 | Named in call light response deficiency | |
| Director of Nursing | Director of Nursing | Named in call light response deficiency and medication administration deficiency |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Sep 22, 2023
Visit Reason
This visit was conducted to investigate complaints IN00417580, IN00410506, and IN00408826 at Bridgewater Healthcare Center.
Findings
No deficiencies related to the allegations in complaints IN00417580, IN00410506, and IN00408826 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00417580, IN00410506, and IN00408826 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 97
Total Capacity: 97
Medicare Census: 8
Medicaid Census: 73
Other Payor Census: 16
Inspection Report
Life Safety
Census: 93
Capacity: 120
Deficiencies: 2
May 8, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/08/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain accurate time and date on the fire alarm system and failure to ensure fire drills included verification of transmission of the fire alarm signal to the monitoring station.
Severity Breakdown
SS=C: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain the fire alarm system to assure accurate time and date information on the fire alarm control panel. | SS=C |
| Failed to ensure 3 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted in four of the last four quarters. | SS=F |
Report Facts
Certified beds: 120
Census: 93
Fire drills missing transmission verification: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding fire alarm system and fire drills; name not fully provided |
Inspection Report
Life Safety
Deficiencies: 0
May 8, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 05/08/23.
Findings
Bridgewater Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 17, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaints IN00391751, IN00392088, IN00401290, and IN00404230 completed on April 17, 2023.
Findings
Bridgewater Healthcare Center was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification and State Licensure Survey and Complaint Investigations.
Complaint Details
The visit included investigation of complaints IN00391751, IN00392088, IN00401290, and IN00404230.
Inspection Report
Annual Inspection
Census: 94
Capacity: 94
Deficiencies: 9
Apr 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including coordination of PASARR screenings, care plan development, catheter care, nutrition and hydration monitoring, respiratory care, behavioral health documentation, medication and treatment documentation, infection prevention and control, and antibiotic stewardship.
Complaint Details
This survey included investigations of complaints IN00387028, IN00387912, IN00388083, IN00391751, IN00392088, IN00394735, IN00396445, IN00396439, IN00398004, IN00401290, IN00404230 and IN00405925. Deficiencies related to complaints were cited at F842, F690, and F0880.
Severity Breakdown
SS=D: 7
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a Preadmission Screening and Resident Review (PASARR) was submitted for level II screening for mental illness for 1 of 3 residents reviewed. | SS=D |
| Failed to develop a care plan addressing antibiotic prophylaxis for a resident waiting for a transplant. | SS=D |
| Failed to ensure catheter bags were positioned below the bladder and changed as ordered for 2 residents. | SS=D |
| Failed to ensure weight monitoring was followed as ordered to identify weight loss for 2 residents. | SS=D |
| Failed to ensure oxygen tubing was dated and oxygen was set at physician prescribed levels for 3 residents. | SS=D |
| Failed to ensure behavioral health notes were available to staff to provide person-centered care for 1 resident. | SS=D |
| Failed to ensure medication/treatment records were documented after administration and correct diagnoses linked to medications for 5 residents. | SS=E |
| Failed to ensure proper infection prevention and control practices including hand hygiene and disposal of soiled briefs for 2 residents. | SS=D |
| Failed to maintain an effective antibiotic stewardship program with monitoring and protocols for antibiotic use. | SS=E |
Report Facts
Survey dates: 2023-04-10 to 2023-04-17
Census: 94
Total Capacity: 94
Deficiencies missing documentation: 20
Fluid drained: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Burdsall | Executive Director | Signed the report |
| Unit Manager 4 | Interviewed regarding catheter care and medication documentation | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication documentation, antibiotic stewardship, and care plans |
| Social Service Director | Social Service Director | Interviewed regarding behavioral health services |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding catheter care and oxygen tubing |
| RN 2 | Registered Nurse | Interviewed regarding catheter care and oxygen tubing |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding catheter care and room cleanliness |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 31, 2022
Visit Reason
The document addresses paper compliance related to the investigation of complaints IN00384803, IN00384821, and IN00385343 completed on July 18, 2022.
Findings
Bridgewater Healthcare Center was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the complaint investigations.
Complaint Details
The visit was related to complaint investigations IN00384803, IN00384821, and IN00385343. The facility was found to be in compliance with the complaints.
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