Inspection Report Summary
The most recent inspection on June 16, 2025, found Bridgewater Healthcare Center in compliance with applicable federal and state regulations and identified no deficiencies. Earlier inspections showed a mixed pattern, with some citations related to resident care, medication administration, and life safety code issues, including staff training on fire suppression systems and corridor obstructions. Complaint investigations were mostly unsubstantiated, except for one in March 2025 where staff were cited for not properly using the kitchen fire suppression system, and another in December 2023 involving deficiencies in call light response, colostomy care, and medication documentation. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed prior life safety deficiencies and shows improvement in recent inspections.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 2
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on the use of Personal Protective Equipment (PPE) and wound care practices.
Findings
The facility failed to ensure PPE was worn in an Enhanced Barrier Precaution room during care for two residents and wound care was not performed according to standard practice, including improper cleaning technique using the same piece of gauze repeatedly.
Deficiencies (2)
Failure to wear gowns as required by Enhanced Barrier Precautions during catheter care for Resident 80.
Improper wound care technique by Wound Nurse 7 using the same piece of gauze to clean both inside and outside of a sacral wound for Resident 77.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse 7 | Named in wound care technique deficiency | |
| CNA 2 | Named in failure to wear gown during catheter care | |
| Clinical Support Nurse 4 | Provided interviews regarding wound care technique and facility policies | |
| Director of Nursing | Director of Nursing | Provided facility policies on catheter care and enhanced barrier precautions |
| Infection Preventionist | Interviewed regarding PPE use failure |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive care plans, medication administration, pharmaceutical services, medication storage, food storage, and infection prevention and control practices.
Findings
The facility failed to ensure comprehensive care plans were properly reviewed and updated for residents with mental health diagnoses, blood pressure medications were administered according to physician orders, narcotic medication reconciliation logs were properly signed, medications were stored and labeled correctly, food items were dated in kitchen refrigerators, and infection control practices including PPE use and wound care technique were followed according to standards.
Deficiencies (6)
Failure to ensure comprehensive care plans were reviewed, revised, and developed by the interdisciplinary team for residents with depression, bipolar disorder, and PTSD.
Failure to administer blood pressure medications according to physician's orders for residents with hypertension.
Failure to ensure staff followed facility policy for reconciliation of controlled medications; missing signatures on narcotic inventory tracker.
Failure to ensure medications were stored in original containers, labeled with open dates, and outdated medications discarded in medication carts and refrigerators.
Failure to ensure food items stored in unit kitchen refrigerators were dated.
Failure to ensure Personal Protective Equipment (PPE) was worn in Enhanced Barrier Precaution rooms and wound care was performed according to standard practice.
Report Facts
Medication administration dates with missing blood pressure recordings: 38
Dates hydralazine not administered despite high systolic blood pressure: 6
Narcotic inventory tracker missing signatures: 8
Narcotic inventory tracker missing signature: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Missed putting on gown for catheter care in Enhanced Barrier Precaution room. |
| Wound Nurse 7 | Wound Nurse | Performed wound care using improper clean to dirty technique. |
| Clinical Support Nurse | Indicated diagnosis and antidepressant medication should have been added to care plan; commented on wound care technique and lack of policy. | |
| Unit Manager 6 | Unit Manager | Indicated nurses should take blood pressure before administering medications with hold parameters and document accordingly. |
| Director of Nursing | Director of Nursing | Indicated PTSD and bipolar disorder should have been included in care plans; hydralazine should have been administered; facility lacked policy on comprehensive care plans. |
| Social Service Director | Social Service Director | Indicated residents with PTSD should have a PTSD assessment initiated. |
| Infection Preventionist 8 | Infection Preventionist | Indicated narcotic inventory tracker must be signed every shift; observed medication storage issues. |
| RN 9 | Registered Nurse | Indicated staff must sign narcotic count sheets every shift; noted insulin needed open dates; observed medication storage issues. |
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Date: May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459409 and IN00459328 at Bridgewater Healthcare Center.
Complaint Details
Complaint IN00459409 and Complaint IN00459328 were investigated with no deficiencies related to the allegations cited.
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.
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
Date: 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.
Complaint Details
Investigation of Complaint Number IN00454659 was completed with the facility found in compliance.
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.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 120
Deficiencies: 1
Date: 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).
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.
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.
Deficiencies (1)
Failed to ensure staff were instructed in the use of the UL 300 hood system in the kitchen.
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
Date: Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448839 and IN00450302.
Complaint Details
Investigation of Complaints IN00448839 and IN00450302 found no deficiencies related to the allegations.
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.
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
Date: Sep 30, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442883 and IN00443571.
Complaint Details
Complaint IN00442883 and Complaint IN00443571 were investigated with no deficiencies cited related to the allegations.
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.
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
Date: 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
Date: 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.
Deficiencies (3)
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.
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.
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.
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
Routine
Deficiencies: 5
Date: Jul 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, communication, nutrition, and behavioral health at Bridgewater Healthcare Center.
Findings
The facility was found deficient in several areas including failure to protect a resident's personal property, incomplete care planning for congestive heart failure, inadequate communication systems for a non-English speaking resident, delayed physician notification of significant weight loss, and failure to identify and treat a resident's hoarding behavior.
Deficiencies (5)
Failed to exercise reasonable care for the protection of a resident's cell phone holder from loss or theft.
Failed to have a comprehensive care plan for a resident with congestive heart failure.
Failed to ensure there was a system in place for communication with a resident who did not speak English as the primary language.
Failed to ensure the physician was notified in a timely manner when a resident had a significant weight change.
Failed to identify and treat a resident's behavioral symptom of hoarding, including hoarding of potentially hazardous food.
Report Facts
Weight loss percentage: 5
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Mentioned in relation to filling out a grievance form for missing phone holder and communication with Resident 91. |
| Head of Housekeeping 4 | Housekeeping Supervisor | Involved in searching for missing phone holder and discussed the incident with Executive Director. |
| Executive Director | Executive Director | Spoke with Housekeeping Supervisor about missing phone holder. |
| Clinical Support Nurse | Clinical Support Nurse | Provided information about care planning deficiencies and BIMS score for Resident 91. |
| Social Services Designee | Social Services Designee | Provided information about Resident 70's hoarding behavior. |
| QMA 5 | Qualified Medication Aide | Observed removing trash from Resident 70's room and described resident's hoarding behavior. |
| Rehab Director | Rehabilitation Director | Indicated speech therapist completed BIMS with Resident 91. |
| Administrator | Facility Administrator | Provided information about Resident 91's diagnosis and Resident 70's anxiety and hoarding behavior. |
Inspection Report
Annual Inspection
Census: 92
Capacity: 92
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to exercise reasonable care for the protection of a resident's personal property (Resident 16).
Failed to have a comprehensive care plan for a resident with congestive heart failure (Resident 3).
Failed to provide necessary care and services to maintain or improve activities of daily living including communication (Resident 91).
Failed to ensure physician notification of significant weight change in a timely manner (Resident 3).
Failed to identify and treat a resident's behavior symptom of hoarding (Resident 70).
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
Date: 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
Date: May 16, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00429003, IN00429791, and IN00434022.
Complaint Details
Complaints IN00429003, IN00429791, and IN00434022 were investigated and found to have no deficiencies related to the allegations.
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.
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
Date: Jan 30, 2024
Visit Reason
This visit was for the investigation of Complaint IN00426545.
Complaint Details
Complaint IN00426545 - No deficiencies related to the allegations are cited.
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.
Report Facts
Census: 88
Total Capacity: 88
Medicare Census: 5
Medicaid Census: 69
Other Payor Census: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Investigation of Complaints IN00421402 and IN00421407; facility found in compliance.
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.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00424975.
Complaint Details
Complaint IN00424975 - No deficiencies related to the allegations are cited.
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.
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
Deficiencies: 3
Date: Dec 18, 2023
Visit Reason
The inspection was conducted in response to complaints related to failure to answer call lights, inadequate colostomy care, and medication administration issues.
Complaint Details
This Federal Tag relates to Complaint IN00421402 and Complaint IN00421407. The complaints involved failure to answer call lights, inadequate colostomy care, and medication administration/documentation issues.
Findings
The facility failed to promptly respond to call lights, failed to properly manage and change a resident's colostomy bag leading to soiling, and failed to administer or document medications and treatments as ordered for multiple residents.
Deficiencies (3)
Facility staff failed to answer a call light for 1 of 1 call light observed flashing on unit 3000.
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.
Facility failed to provide medications/treatments per the physician's order and failed to document the reason for omission for 2 of 3 residents reviewed for medication administration.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication omissions: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Named in failure to respond to call light finding | |
| LPN 4 | Licensed Practical Nurse | Named in colostomy care deficiency and medication administration observation |
| Director of Nursing | Director of Nursing | Provided interviews and facility policies related to call light response, colostomy care, and medication administration |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 3
Date: Dec 18, 2023
Visit Reason
The visit was conducted for the investigation of complaints IN00421402, IN00421407, IN00422706, and IN00424361 at Bridgewater Healthcare Center.
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.
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.
Deficiencies (3)
Facility staff failed to answer a call light for 1 of 1 call light observed flashing on unit 3000 (Room 3012).
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).
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).
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
Date: Sep 22, 2023
Visit Reason
This visit was conducted to investigate complaints IN00417580, IN00410506, and IN00408826 at Bridgewater Healthcare Center.
Complaint Details
Complaints IN00417580, IN00410506, and IN00408826 were investigated and found to have no deficiencies related to the allegations.
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.
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
Date: 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.
Deficiencies (2)
Failed to maintain the fire alarm system to assure accurate time and date information on the fire alarm control panel.
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.
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
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Apr 17, 2023
Visit Reason
The inspection was conducted based on complaints (IN00404230, IN00401290, IN00392088, and IN00391751) to investigate medication and treatment documentation practices and ensure correct diagnoses were linked to medications.
Complaint Details
This Federal tag relates to Complaint IN00404230, IN00401290, IN00392088, and IN00391751. The facility was found deficient in documentation and diagnosis linkage for 5 residents (Residents F, C, D, E, and 89).
Findings
The facility failed to ensure medication and treatment records were properly documented after administration and failed to link correct diagnoses to medications for 5 residents reviewed. Missing documentation was found in Medication Administration Records (MAR) and Treatment Administration Records (TAR) across multiple months for various medications and treatments.
Deficiencies (2)
Failure to document administration or non-administration of medications and treatments in MAR and TAR for multiple residents.
Failure to ensure correct diagnosis was linked to medication orders, specifically Gabapentin prescribed for health maintenance instead of diabetic neuropathy.
Report Facts
Dates with missing documentation: 30
Medication dosage: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and documentation practices, and diagnosis linkage for medications. |
| Corporate Support Nurse | Corporate Support Nurse | Interviewed regarding missing documentation and facility monitoring practices. |
| Unit Manager 4 | Unit Manager | Interviewed regarding MAR/TAR sign-off procedures. |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 17, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to submit required PASARR screenings, incomplete care plans, improper catheter care, inadequate weight monitoring, oxygen therapy issues, missing psychiatric notes, incomplete medication and treatment documentation, and deficiencies in infection prevention practices.
Deficiencies (9)
Failed to ensure a Preadmission Screening and Resident Review (PASARR) was submitted to request a level II screening for mental illness for 1 of 3 residents reviewed.
Failed to develop a care plan for a resident with cirrhosis of the liver addressing antibiotic prophylaxis.
Failed to provide appropriate catheter care including positioning catheter bag below bladder level and changing catheter bags as ordered.
Failed to ensure weight monitoring was followed as ordered to identify weight loss at an earlier stage for 2 of 7 residents reviewed for nutrition.
Failed to ensure oxygen tubing was dated and oxygen was set at physician prescribed levels for 3 of 3 residents reviewed for oxygen therapy.
Failed to ensure behavior health notes were available to staff to provide person centered and individualized care approaches for 1 resident requiring behavioral health services.
Failed to ensure medication/treatment records were documented after administration and failed to ensure correct diagnoses were linked to medications for 5 residents.
Failed to ensure dressing change was completed using clean gloves and hand hygiene and failed to ensure soiled briefs were properly disposed of.
Failed to follow an antibiotic stewardship program including antibiotic use protocols and monitoring for 6 of 12 months reviewed.
Report Facts
Fluid drained: 1000
Weight loss percentage: 7.8
Medication doses missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 4 | Performed drainage procedure on Resident 304 and acknowledged hand hygiene lapses | |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan deficiencies, antibiotic stewardship, and medication documentation |
| Social Service Director 6 | Social Service Director | Interviewed regarding behavioral health services and psychiatric notes for Resident 19 |
| Nurse Practitioner 8 | Nurse Practitioner | Provided orders for Resident 49 and interviewed about weight monitoring orders |
| RN 2 | Registered Nurse | Interviewed regarding catheter care and oxygen tubing |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding catheter care and oxygen tubing |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding catheter bag placement and room odor |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
Complaint Details
The visit included investigation of complaints IN00391751, IN00392088, IN00401290, and IN00404230.
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.
Inspection Report
Annual Inspection
Census: 94
Capacity: 94
Deficiencies: 9
Date: Apr 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
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.
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.
Deficiencies (9)
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.
Failed to develop a care plan addressing antibiotic prophylaxis for a resident waiting for a transplant.
Failed to ensure catheter bags were positioned below the bladder and changed as ordered for 2 residents.
Failed to ensure weight monitoring was followed as ordered to identify weight loss for 2 residents.
Failed to ensure oxygen tubing was dated and oxygen was set at physician prescribed levels for 3 residents.
Failed to ensure behavioral health notes were available to staff to provide person-centered care for 1 resident.
Failed to ensure medication/treatment records were documented after administration and correct diagnoses linked to medications for 5 residents.
Failed to ensure proper infection prevention and control practices including hand hygiene and disposal of soiled briefs for 2 residents.
Failed to maintain an effective antibiotic stewardship program with monitoring and protocols for antibiotic use.
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
Date: 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.
Complaint Details
The visit was related to complaint investigations IN00384803, IN00384821, and IN00385343. The facility was found to be in compliance with the complaints.
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.
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