Bridgewater Center for Rehab & Nursing L L C

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a process was in place for residents to have their grievances addressed appropriately for 349 of 349 residents residing in the facility. Specifically, 12 of 12 anonymous residents present at the resident group meeting stated they did not know where to obtain grievance forms, their right to file grievances anonymously, and who the grievance officer was. The residents present at the meeting stated their views, grievances, or recommendations voiced during resident council group meetings were not acted upon and responded to with a rationale and there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for one of one main kitchen, two of seven rolling coolers (Units 2B and 5A rolling coolers), and two of four unit pantries (Units 4A and 5A pantries). Specifically, in the main kitchen prepared foods were not cooled properly, multiple single serve milk cartons were past their best by date, several food items were stored in packages on the floor or loose on the floor of the freezer, two handwashing sinks did not have access to paper towels and areas of the kitchen were unclean; The Units 2B and 5A rolling coolers did not maintain temperature for proper cold storage; the Unit 5A pantry had several areas that were unclean and the refrigerator did not maintain temperature; [...]

Inspectors wroteBased on observations, record review, and interviews (IQIES intake 2647397), the facility failed to ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for three of three residents (Residents #19, #41, and #72) reviewed and for 10 of 12 anonymous residents present at a resident group meeting. Specifically, Resident #19's wheelchair was unclean and in disrepair; Resident #41's ceiling dripped liquid over their bed; Resident #72's clothing was improperly labeled and was worn by another resident; and 10 anonymous residents reported their clothing was not labeled properly, was not returned to them after laundering and was distributed to other residents.

Inspectors wroteBased on observations, record review, and interviews, (IQIES intake 2991234), the facility did not ensure a safe, clean, comfortable, and homelike environment for four of seven resident units (Units 2A, 3A, 4A and 5A) reviewed. Specifically, Units 2A, 3A, 4A and 5A were unclean and in disrepair.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for three of seven medication carts (Unit 4A, Unit 4B, and Unit 5A). Specifically, the Unit 4A medication cart contained eye drops and inhalers that were not dated when opened, a blister pack of medications expired 06/05/2026, one insulin pen without a pharmacy label and one insulin pen that was not dated when opened; the Unit 4B medication cart contained an insulin pen that was not dated when opened; and the Unit 5A medication cart had unlabeled medication in a cup, a blister pack of medication that expired 01/15/2026, and an inhaler with two different open dates on it.

Inspectors wroteBased on observations and interviews (IQIES intakes 2991229 and 3008641) the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two test trays (06/08/2026 lunch tray and 06/09/2026 breakfast tray) sampled, and for 10 of 12 anonymous residents present at the Resident Council meeting. Specifically, the 06/08/2026 breakfast tray and the 06/09/2026 lunch tray had hot foods served below 130 degrees Fahrenheit, cold foods served above 49 degrees Fahrenheit and were not palatable; and 10 anonymous residents stated the hot food was cold and flavorless, milk was often served spoiled, lettuce was often brown, and the facility often ran out of food and cups.

Inspectors wroteBased on observations, record review, and interviews (iQIES intake #2997455 and 3008641), the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of eight residents (Resident #13 and Resident #376) reviewed and two of two staff (Housekeeper #64 and Certified Nurse Aide #61) observed. Specifically, Resident #13 was on contact precautions for clostridioides difficile (a highly infectious bacteria that causes diarrhea) and Certified Nurse Aide #61 walked into the resident's room to retrieve a meal tray without wearing a gown or gloves or washing their hands with soap and water; Resident #376 did not have a contact precaution sign on their door with clostridioides difficile results pending; [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one of one main kitchen walk-in freezers. Specifically, the main kitchen walk-in freezer was malfunctioning and did not have an out of service sign posted to prevent staff from using it for food storage.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one of one resident (Resident #361) reviewed. Specifically, Resident #361 had two budesonide-formoterol fumarate dihydrate aerosol inhalers (used for opening airway) in their room and there was no documented evidence of an assessment or a physician order for the resident to safely self-administer medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all investigations were thoroughly investigated to rule out abuse, neglect and mistreatment for one of one resident (Resident #298) reviewed. Specifically, Resident #298 sustained an injury of unknown origin, a right hip fracture, and a thorough investigation was not completed to rule out abuse, neglect, or mistreatment and the incident was not reported to the New York State Department of Health as required.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement the comprehensive care plan for one of one resident (Resident #16) reviewed. Specifically, Resident #16's comprehensive care plan documented the resident required supervision with the potential for dependent care with eating and the resident was observed feeding themself without staff supervision.

Inspectors wroteBased on observations, record review, and interviews, (IQIES 2991229), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three residents (Residents #10, #72, and #376) reviewed. Specifically, Resident #72 had a self-reported skin impairment they requested only the wound team or the provider to assess, their request was not communicated to the provider or the wound team, and the skin impairment was not assessed timely; Resident #10 had a wound dressing applied without an order; and Resident #376 had a central line (a venous catheter used to give medicine, fluids, or obtain blood samples) and there was no physician order for its use and or directions for monitoring of the site.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for one of two residents (Resident #18) reviewed. Specifically, Resident #18's right-hand palm guard (used to prevent contractures and protect the skin) was not applied as ordered.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for one of 10 residents (Resident #155) reviewed. Specifically, Resident #155 had a history of multiple falls including one fall with major injury, and they did not have fall mats in place as care planned.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of six residents (Resident #194) reviewed. Specifically, Resident #194 had a low body mass index (a calculated measure of weight relative to height) and was not assisted with meals and did not receive their nutritional supplements and other food items as care planned.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of two residents (Resident #318) reviewed. Specifically, Resident #318 had a tracheostomy (a surgical opening in the neck to allow breathing) and was not provided with consistent oral care per professional standards.

Inspectors wroteBased on observations, record review, and interviews (IQIES intake 482787), the facility failed to ensure accommodation of resident food preferences for one of one resident (Resident #9) reviewed. Specifically, Resident #9's meal trays were missing preferred food items and included foods they requested not to receive.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00355972, NY00357410, NY00358321, and NY00367882) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 8 resident units (Units 2 A, 3 A, and 4 A) reviewed. Specifically, Unit 2 A had a strong smell of urine, unclean bedrooms floors, a bathroom with brown splatter on the toilet, and an over bed table with food debris; Unit 3 A's dining room floor was unclean and sticky, there was debris on the base of the food carts, and brown material on a raised toilet seat in a resident room; and Unit 4 A had a continuously running sink in a resident room, unclean floors in multiple resident rooms, and food splatter on the floors and walls.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure that each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals (2/21/2025 and 2/24/2025 lunch meals) reviewed. Specifically, the 2/21/2025 and 2/24/2025 lunch meals were not served at palatable and appetizing temperatures and the 2/24/2025 lunch meal was not palatable or attractive. Additionally, 7 of 7 anonymous residents at the Resident Council meeting stated the food was not appetizing and not served at appropriate temperatures; and Residents #46, #47, and #210 stated the food was not served at appetizing temperatures.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and on1 unit (Unit 2A). Specifically, the main kitchen had multiple unclean surfaces, there were stored food items past their expiration dates, and staff did not wear hair nets. Unit 2A had a steam table with dried food, discolored water, and debris: and there was debris and 3 mouse traps behind the unit ice machine.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00358321 and NY00368342) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 11 residents (Residents #46 and #99) reviewed. Specifically, Residents #46 and #99 were not assisted with showering as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00370596, NY00368342, and NY00355972) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 2 residents (Resident #99 and #236) reviewed. Specifically, for Resident #236 Licensed Practical Nurses #14 and #17 administered medications outside of acceptable time parameters, a tube feeding was not given and documented as administered, medications were signed as given prior to administration, signed as given on time when they were given late, and treatments were signed completed when they were not; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure each resident who required colostomy (a surgical opening in the abdomen that allows waste to pass out of the body) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #745) reviewed. Specifically, Resident #745 had a colostomy and there were no orders for ongoing monitoring, there was no order for the wafer of the 2 piece system, there was no care plan for the colostomy, no care instructions for the drainage pouch, and staff were unaware the resident had a colostomy. Additionally, the drainage bag was observed not in place and was not emptied timely when it was in place.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure residents who required dialysis (a process that filters the blood during kidney failure) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #257) reviewed. Specifically, the facility did not consistently assess Resident #257 vital signs (blood pressure, heart rate, respirations, temperature) prior to dialysis, review the dialysis communication book sheets upon return from dialysis, or notify the provider of incomplete and refused dialysis procedures.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #153) reviewed. Specifically, Resident #153 had an extensive mental health history, did not have person-centered mental health interventions, and Preadmission Screening and Resident Review Level II recommendations were not implemented into the resident's plan of care. Additionally, Resident #153 hid butter knives under their mattress and there were no documented social services follow ups with the resident following their behavioral symptoms.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #744) reviewed Specifically, Resident #744 did not receive Abilify (an antipsychotic medication) for 4 consecutive days (10 doses).

Inspectors wroteBased on observations and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts (2B East cart) reviewed. Specifically, the 2B East medication cart contained 4 opened undated insulin vials, 7 opened undated insulin pens, and one expired insulin vial. Additionally, 2 vials of vaccines (Prevnar, pneumococcal vaccine and Abrysvo, respiratory syncytial virus vaccine) were observed sitting on top of the medication cart unsecured and unattended. The facility policy, Insulin Orders, revised 11/2016, documented the pharmacy assigned a 28-day expiration date on all insulin pen delivery devices once removed from the refrigerator. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #49 and #226) reviewed. Specifically, Resident #226 was on transmission-based precautions (enhanced barrier precautions) and Licensed practical nurse #1 performed gastrostomy tube (feeding tube) care without wearing required personal protective equipment. [...]

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00308658, NY00311004, and NY00298919) surveys conducted 3/12/23-3/16/23, the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 resident rooms (resident rooms 520, 505, 504, 448, 432, 430, 425, 406, 405, 403, 361, 359, 346, 260, and 248); 10 resident common areas (fifth floor north hall shower room, fifth floor hall near the 5A emergency exit stairwell, fifth floor north hall bathroom, fourth floor north shower room, fourth floor north dining room, third floor south shower room, third floor south dining room, second floor hall near resident room [ROOM NUMBER], and second floor south training bathroom); and 1 resident device (resident chair in fifth floor hall). [...]

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00302292) surveys conducted 3/21/23-3/28/23, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance and enhancement of quality of life for 2 of 7 (Residents # 24 and 165) reviewed. Specifically, Resident #24 was not provided their bathing preference of a shower; and Resident #165's urinary catheter collection bag was uncovered with the contents visible.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/21/23-3/28/23, the facility failed to ensure residents were free of any significant medication errors for 1 of 1 resident (Resident # 250) reviewed. Specifically, Resident #250 had physician orders to receive nothing by mouth (NPO) and had six medications ordered with a route of administration by mouth (PO).

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 3/21/23-3/28/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 6 medication carts (Units 4-A and 4-B) and 2 of 4 medication storage rooms (Units 2-A and 4-A) observed. Specifically, Units 2-A, 4-A, and 4-B had expired resident specific medications, stock medications and biologicals in the medication carts, medication room and/or the medication room refrigerators. The facility policy Insulin Administration via a Pen reviewed/revised 4/2019 documented pharmacy assigned a 28 day expiration date on all insulin pen delivery devices once removed from the refrigerator. Insulin pens were for single resident use only. [...]