Bridgetown Nursing And Rehabilitation Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to properly assess a resident's Pre admission Screening and Resident Review (PASARR) screen. The facility failed to identify a mental health diagnosis. This affected one (#03) out of four residents reviewed for PASARR screening. The facility census was 41. Findings include:Medical record review for Resident #03 revealed he was admitted to the facility on [DATE]. His diagnoses included, essential primary hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus (DM), post-traumatic stress disorder (PTSD), anxiety, chronic fatigue, gastro-esophageal reflux disease (GERD), and bipolar disorder. Review of Minimum Data Set Assessment (MDS) for Resident #03 dated 04/10/25 revealed he was cognitively intact. Resident #03 was dependent on staff for medication administration. Resident #03 required set up assistance from staff with meal set up, oral hygiene, and upper body dressing. Resident #03…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interviews, and policy review, the facility failed to ensure residents had complete and accurate comprehensive care plans. This affected three (#1, #3 and #44) of fourteen residents reviewed for care plans. The facility census was 41.Findings include: 1. Medical record review for Resident #01 revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (AFIB), sepsis, gastro-esophageal reflux disease (GERD), primary generalized arthritis, vascular dementia, anxiety, congestive heart failure (CHF), chronic obstructive pulmonary disease, asthma, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed he had impaired cognition. Resident #03 was dependent on staff for medication administration, toilet use, bathing, and personal hygiene. He required maximum assistance from staff with oral hygiene. He required supervision from staff with eating. Review of the care plans for Resident #01 revealed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interviews, staff interviews, and policy review, the facility failed to ensure residents were provided care conferences and revise care plans as needed. This affected two (#05 and #44) of fourteen residents sampled for care plans. The census was 41.Findings include: 1. Medical record review for Resident #05 revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, obesity, diabetes mellitus (DM), anxiety disorder, gastro-esophageal reflux disease (GERD), and schizoaffective disorder. Review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed she was cognitively intact. Resident #05 was dependent on staff for medication administration, she required set up assistance from staff for meals, oral hygiene, toilet use, dressing and personal hygiene. Review of the progress for Resident #05 dated 05/29/25 revealed Resident #05 reported she rolled out of bed the previous Saturday (05/24/25). Resident #05 reported to the nurse she slipped when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure residents were wearing physician ordered splint devices. This affected one (#16) of one residents reviewed for range of motion. The facility census was 41.Findings include:Review of Resident #16's medical record revealed an admission date of 06/07/24, with diagnoses including peripheral vascular disease and supraventricular tachycardia. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment and occasionally refused care. Review of physician orders dated 05/25/25 for a left resting hand splint to be applied in A.M. and check skin integrity every shift. Review of care plan dated 06/05/25 for the left wrist splint, to check skin every shift upon don and doff for signs and symptoms of skin break down. Review of care plan revealed no indication of refusal of care. Observation on 09/02/25 at 9:30 A.M. revealed Resident #16 did not have left hand splint. Observation on 09/02/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to notify the resident's representative of a significant change in the resident's care and treatment. This affected one (Resident #34) of three residents reviewed for notification of change in condition. The census was 42. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE] with presence of prosthetic heart valve, cerebral infarction with left sided hemiplegia and hemiparesis, vascular dementia, atrial fibrillation, and obesity. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #34 had moderate cognitive impairment and was always incontinent of bowel and bladder. The resident required supervision with eating, maximal assistance with oral hygiene and was dependent for toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders for Resident #34 revealed that on 06/17/24, Nurse Practitioner (NP) #1001…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to complete comprehensive care plans on residents. This affected two (#14 and #15) residents of the four residents reviewed for care plans. The facility census was 39. Findings include: 1) Review of medical record for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of the care plan for Resident #14 revealed there was no care plan related to the resident's skin integrity and the Stage II pressure injury. Observation of wound care for Resident #14 on 04/15/24 11:34 A.M. provided by Wound Care Physician #53, revealed the resident had a stage two pressure ulcer on the right buttock that was being debrided. Interview with Wound Care Doctor #53 at the same time, verified the resident had a stage two pressure ulcer on her right buttock. Interview with Minimum Data Set (MDS) Coordinator #51 on 04/16/24 at 11:15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, review of online resources from the Centers for Disease Control (CDC) and review of facility policy, the facility failed to follow infection control procedures during dressing changes. This affected one (#14) resident of the three residents reviewed for wound care. The facility census was 39. Findings include: Record review for Resident #14 revealed the resident was admitted on [DATE] with diagnoses including but not limited to breast cancer, kidney failure, atrial fibrillation, and acute cystitis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition. Observation of would care/dressing change for Resident #14 on 04/15/24 11:34 A.M. with Licensed Practical Nurse (LPN) #54 and State Tested Nursing Assistant (STNA) #55 revealed LPN #54 removed a soiled incontinence brief and replaced it with a clean one. LPN #54 then cleansed the open wound on Resident #14's right buttock with saline and gauze. LPN #54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to notify residents in advance of menu changes. This had the potential to affect 37 residents who received food from the kitchen. The facility census was 38. Findings include: During observation on 05/16/22 at 12:10 P.M., the menu posted in the kitchen listed the lunch meal as baked veal cutlet, creamy dill sauce, bow tie pasta, roasted brussels sprouts, wheat dinner roll or bread, and blushing pears. Concurrent observation of the tray line revealed residents were served a cheeseburger, french fries, and fruit. During interview on 05/16/22 at 12:15 P.M., Dietary Manager (DM) #40 stated the residents do not like veal, so she normally serves them country fried steak, which she was not able to get, so she served burgers today. When questioned, DM #40 stated the residents had not been notified of the menu change prior to the meal and further stated the menus posted on the resident units were not current. DM #40 stated some residents call the kitchen each day to find out what they are getting and she lets them know at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of food borne illness and failed to ensure kitchen equipment and fixtures were maintained in a clean and sanitary manner. This had the potential to affect 37 residents who received food from the kitchen. The facility census was 38. Findings include: 1. Observation on 05/16/22 at 9:15 A.M., the walk-in refrigerator revealed a carton of pasta salad open to air and unsealed; another carton of pasta salad wrapped in plastic wrap and dated 05/05/22; seven muffins in a box, loosely covered, open to air, and not dated; a gallon Ziploc bag of american cheese slices unzipped and open to air; a box of donut holes unlabeled, not dated, and open to air; and a gallon Ziploc back of turkey lunch meat not labeled and not dated. Observation of the freezer revealed a bag of frozen cookies which was open to air and not labeled or dated and a box of frozen hamburger patties which was open to air. Observation of the dry storage area revealed a package of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview and review of facility surety bond, the facility failed to ensure the surety bond was sufficient to cover the balance of resident funds accounts. This affected 26 Residents (#3, #4, #5, #6, #8, #10, #11, #13, #14, #19, #20, #21, #22, #23, #26, #27, #28, #30, #31, #32, #34, #37, #39, #41, #52, #305) whom had personal funds managed by the facility. The census was 55. Findings include: Review of personal trust account balances for Residents #3, #4, #5, #6, #8, #10, #11, #13, #14, #19, #20, #21, #22, #23, #26, #27, #28, #30, #31, #32, #34, #37, #39, #41, #52, #305 revealed a total balance of all accounts as $10,879.33. Review of facility surety bond dated 08/09/12 revealed a policy term of 06/01/12 to 06/01/13 with a bond limit of $10,000.00. Interview on 04/11/19 at 4:06 P.M. with the Administrator reported the surety bond was active and renewed automatically every year. The Administrator acknowledged the surety bond limit was $10,000.00 and the resident accounts exceeded this amount.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of facility policy, and staff interview, the facility failed to timely notifiy each resident's physician when there was a significant change in their physical status. This affected two residents (#15, #14) of five reviewed for nutrition.The facility census was 55. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, altered mental status, syncope and collapse, and dysphagia. Review of Resident #15's quarterly minimum data set (MDS 3.0) dated 01/29/19, identified the resident as having poor short and long term memory, having severely impaired cognitive skills, and requiring the extensive assistance of one staff person to eat. The resident's height was 66 inches and weight was 148 pounds at the time of the assessment. Resident #15 was identified as having weight loss at that time, and not on a prescribed weight loss regimen. Resident #15's current plan of care for being at nutritional risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage was provided timely. This affected two (#55 and #304) of three residents reviewed for Beneficiary Protection Notification. The census was 55. Findings include: 1. Review of Notice of Medicare Non-Coverage revealed Resident #55 was provided written notice on 01/09/19 of therapy services ending on 01/10/19. 2. Review of Notice of Medicare Non-Coverage revealed Resident #304 was provided written notice on 03/23/19 of therapy services ending on 03/24/19. Interview on 04/11/19 at 4:21 P.M. with Social Service Designee (SSD) #58 verified notice of Medicare Non-Coverage were provided to Residents #55 and #304 only a day prior, not 48 hours prior, to the end of therapy services.

Based on observations, record review and staff interviews, the facility failed to ensure privacy for a resident. This affected one (Resident #7) of two residents reviewed for privacy. The facility census 55. Findings Include : Record review for Resident #7 revealed diagnoses including diabetes, high blood pressure, and depression. The most recent quarterly Minimum Data Set 3.0 (MDS) dated on 01/17/19 revealed the resident had no cognitive impairments and required minimal assistance of one with all care needs. The most recent Activities of Daily Living (ADL) plan of care revealed the resident needed minimal assistance and set up for hygiene. Observation during an interview on 04/09/19 at 3:00 P.M. revealed the resident had a private room. No privacy curtain was noted. When the door was opened you could see the resident from the hall way. While conducting the interview, Office employee (OE) #70 and the foot doctor entered the resident's room with out knocking. OE #70 confirmed she should have knocked before entering. Interview on 04/09/19 at 3:00 P.M. revealed Resident #7 noted she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff and resident interview, the facility failed to ensure each resident was provided with a homelike environment in which their personal belongings were kept in a clean and orderly manner. This affected one resident (#16) of twenty-one resident's current resident's reviewed. Findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, dysphagia, major depressive disorder, chronic obstructive pulmonary disease, anxiety disorder, and abnormal posture. The facility completed a quarterly minimum data set (MDS) assessment of the Resident #16's cognitive and physical functional abilities dated 01/29/19. The 01/29/19 assessment identified the resident as having good memory, orientation, and recall, and requiring the physical assistance of at least one staff person for bed mobility, transferring, and dressing. The resident did not walk and accessed her environment in a special motorized wheel chair. The resident was interviewed, and observed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a written notice including reasons for transfer/discharge and appeal rights was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected one resident (#56) of one resident reviewed for Hospitalization. The facility census was 55. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses including pneumonia, acute respiratory failure with hypoxia, hypertension, diabetes mellitus type 2, atrial fibrillation, generalized anxiety disorder, adult failure to thrive, and anemia due to anti-neoplastic chemotherapy. Review of the Resident #56's nursing progress notes revealed the resident was sent out to the hospital on [DATE] due to a change in her condition. On 02/24/19 at 1:33 P.M., Licensed Practical Nurse (LPN) #52 documented the resident stated she was not feeling very well today. LPN #52 took and recorded the resident's vital signs which indicated the Resident #56's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, the facility failed to ensure a dependent resident received daily care. This affected one (#30) of three residents reviewed for activities of daily living. The facility census was 55. Findings Include : Review of Resident #30's medical record revealed diagnoses including seizure disorder, anxiety, depression and parkinsons. Review of Resident #30's most recent annual Minimum data Set 3.0 (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance of one with her care. The MDS also noted the resident was incontinent of urine and had a colostomy. Review of the plan of care for activities of daily living notes the resident needed assistance with her colostomy daily and had behaviors of removing her colostomy bag. Observation of the resident on 04/09/19 at 3:05 P.M., revealed the residents hair was uncombed. The resident's clothes were soiled with brown liquid, her teeth were caked with food and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to provide care for each resident consistent with physicians orders. This affected one (#35) of one resident reviewed for Respiratory Care, and one (#4) of two residents reviewed for Edema. The facility census was 55. Findings include: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses including pneumonia, infection and inflammatory reactions, chronic respiratory failure with hypoxia, hypertensive heart disease, atrial fibrillation, breakdown of cystostomy catheter, and dementia. The facility completed an admission minimum data set (MDS) assessment of Resident #35 dated 03/15/19. The 03/15/19 assessment identified the resident as having severely impaired memory and recall, and shortness of breath with exertion, when sitting at resident and when lying flat. The assessment also identified the resident as receiving oxygen therapy while a resident. Review of Resident #35's admission and current physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of facility policy, and staff interviews, the facility failed to ensure to timely address a resident's significant weight loss. This affected two (Resident #15 and Resident #14) of five residents reviewed for Nutrition. The facility census was 55. Findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, altered mental status, syncope and collapse, and dysphagia. Review of Resident #15's quarterly minimum data set (MDS 3.0) dated 01/29/19, identified the resident as having poor short and long term memory, having severely impaired cognitive skills, and requiring the extensive assistance of one staff person to eat. The resident's height was 66 inches and weight was 148 pounds at the time of the assessment. Resident #15 was identified as having weight loss at that time, and not on a prescribed weight loss regimen. Resident #15's current plan of care for being at nutritional risk revealed the plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff and resident interview, the facility failed to provide each resident with medically-related social services to assist in resolving roommate issues which impacted their psychosocial well-being. This affected two residents (#13, #39) of three reviewed for resident to resident interactions. The facility census was 55. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities, major depressive disorder, anxiety disorder, and abnormal posture. The facility completed a quarterly minimum data set assessment (MDS 3.0) of the resident's cognitive status dated 01/21/19. The 01/21/19 assessment identified the resident as having good memory, orientation, and recall. Resident #39 was admitted to the facility on [DATE] with diagnoses including aphasia, hemiplegia, seizure disorder, anxiety disorder, and depression. The facility completed a quarterly minimum data set (MDS 3.0) assessment of the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.