Bridgeville Rehabilitation & Care Center

In the surveyor’s words

From the most serious findings on record at Bridgeville Rehabilitation & Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 2, 2025

  Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of twelve residents (Resident R19). This failure created an immediate jeopardy situation for 12 of 12 residents (Residents R19, R4, R17, R20, R21, R22, R23, R24, R25, R26, R27, and R28). This was identified as past non-compliance. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief… […]

• Immediate jeopardy, isolatedF689Jan 14, 2026

  Based on a review of facility policy, clinical records, staff interviews, and facility reported incident, it was determined that the facility failed to make certain that residents were protected from harmful chemicals that resulted in actual harm for a resident (Resident R1) when the resident ingested ethylene glycol (chemical found in antifreeze) resulting in hospitalization. This failure created an Immediate Jeopardy situation for one of 108 residents. Findings include: Review of the facility policy, Accidents/Incidents, indicated the facility will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred involving a resident who is receiving services. […]

• Immediate jeopardy, isolatedF742Jan 14, 2026

  Based on review of facility documentation, observation and staff interview it was determined that the facility failed to ensure that the residents received appropriate treatment and services to correct assessed problems associated to an event of self-harm for one of two residents reviewed (Resident R1) resulting in actual harm, transfer to the hospital (Resident R1); and the investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, resulting in an Immediate Jeopardy situation for one of 108 residents (Resident R1). […]

• Actual harm, isolatedF690Aug 23, 2024

  Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain that residents with suprapubic urinary catheters received appropriate treatment and services consistent with professional standards during catheter care by monitoring placement and skin, changing the catheters and providing care, resulting in actual harm as evidenced by penile split and traumatic insertion and removal for one of three residents (Resident R64) and failure to change a urinary catheter every 30 days as ordered for one of three residents (Resident R2). […]

• Actual harm, isolatedF689Sep 2, 2021

  Based on review of facility policy, clinical records, facility documentation and staff interviews, the facility failed to provide adequate supervision to prevent a fall with injuries for one of six residents reviewed (Resident R124), resulting in harm with a fracture of the left radius and ulna fracture (wrist fracture) that resulted in a transfer to the hospital. Findings include: Review of facility policy Accidents/Incidents dated 1/1/2021 & 8/31/2021, indicated that An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident. […]