Bridgewater Healthcare Center

In the surveyor’s words

From the most serious findings on record at Bridgewater Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF725Jun 21, 2021

  Based on observation, interview and record review, the facility failed to have sufficient staff with the appropriate competencies and skills sets to provide nursing care to residents to ensure their safety and care needs were met. Multiple residents called 911 to the facility during the night shift to seek help in care needs and while the police were at the facility, they observed the lack of available staff to ensure safety and medical needs were addressed. The police department had been called a minimum of 13 times since [DATE]. Residents, family and staff interviews indicated a lack of staff to provide personal and medical care. […]

• No harm, potential for more than minimal, widespreadF921Mar 10, 2022

  Based on observation and interview, the facility failed to ensure the resident common areas, halls and floors were clean as well as 2 of 11 resident rooms observed for cleanliness. (5000 unit, 3000 unit 2000 unit, Room 3002 and 3006) Findings include: 1. During an initial tour of the facility, on 03/07/22 at 5:20 a.m., the following were observed: a. The 5000 unit common area was noted to have dirty Styrofoam cups and food crumbs on the table tops. The tops were sticky with rings from dirty cups left on them and scattered food crumbs and trash. b. The 3000 unit floors were noted to have dried sticky stains throughout, paper trash on the hall floor and in the dining area. 2. During a tour of the facility, on 03/07/22 at 10:54 a.m., the following were observed: a. […]

• No harm, potential for more than minimal, patternF684May 13, 2026

  Based on interview and record review, the facility failed to ensure insulin was administered according to the physician's order or new orders were documented, daily weights were obtained according to the physician's order, and cardiac medications were held according to the physician's ordered parameters for 4 of 4 residents reviewed for quality of care. (Resident 21, 6, 13 and 117)Findings include: 1. During an interview, on 5/7/26 at 10:15 a.m., Resident 21 indicated her blood sugars readings were up and down. The clinical record for Resident 21 was reviewed on 5/11/26 at 10:58 a.m. […]

• No harm, potential for more than minimal, patternF842Apr 17, 2023

  Based on interview and record review, the facility failed to ensure the medication/treatment records were documented after the administration of medications or treatments and failed to ensure the correct diagnoses was linked to a medication for 5 of 5 residents reviewed for complete and accurate documentation. (Residents F, C, D, E and 89) Findings include: 1. The record for Resident F was reviewed on 04/17/23 at 1:30 p.m. Diagnoses included, but were not limited to, chronic kidney disease, acute kidney failure, and type 2 diabetes mellitus. During the review of the Medication and Treatment records, the following were missing documentation in the January, February, and March records. […]

• No harm, potential for more than minimal, patternF881Apr 17, 2023

  Based on interview and record review, the facility failed to follow an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for 6 of 12 months reviewed for antibiotic stewardship. Finding includes: A review of the Facility Assessment Tool, dated 11/2021 through 10/2022, indicated the facility had an antibiotic stewardship program. The Director of Nursing (DON) started gathering information, documenting, and tracking infections for the program on 4/14/23. During an interview, on 4/17/23 at 9:24 a.m., the DON indicated she did not have any information filled out or track infections and trends until a few days ago. […]