Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgewater Park Health & Rehabilitation Center during CMS and state inspections, most recent first.
Dietary Manager Lacked Required Qualifications: The facility failed to ensure the staff member serving as Dietary Manager met the required credentials for the role. Record review showed only a high school education and no documentation of a completed food safety and management course, and the staff member confirmed he was not a Certified Dietary Manager and had no other kitchen management credentials. The Administrator also confirmed the required course had not been completed, despite the job description requiring specific qualifications for the position.
Inaccurate MDS Did Not Reflect Depression Diagnosis. A resident admitted with depression and a history of dementia had an admission MDS that did not list depression under Active Diagnoses. The resident had physician orders for antidepressants for depression, the MAR showed both meds were administered, and a psychiatry note listed depression as the chief complaint. The MDS coordinator acknowledged the diagnosis was in the system and the MDS needed correction, and the DON stated the facility followed the RAI.
The facility failed to coordinate PASRR updates for three residents with newly evident or possible mental health conditions. One resident developed delusions and agitation and was later treated with quetiapine, while two other residents had diagnoses including GAD, MDD, and dementia/Alzheimer’s disease, yet their Level I PASRRs still showed no mental illness or suspicion of MI. The DON and Social Services Director acknowledged the PASRRs should have been corrected.
The facility failed to follow ordered care for a resident with a shin skin tear, as the wound dressing was observed without a date and staff confirmed it had been changed without being dated. The same resident also had multiple missed daily weights despite a CHF order for morning weights. In addition, staff did not follow ordered Humalog sliding-scale parameters for another resident, with several high blood glucose readings documented on the MAR.
Failure to complete ordered weight monitoring for two nutritionally at-risk residents. Physician orders directed daily weights, but the TARs showed missing or N/A entries and the weight records were incomplete for both residents. One LPN said the person assigned to do weights was sometimes unavailable, and the DON stated the weights for both residents were not done and floor staff did not pick up on doing them.
Failure to provide ordered oxygen therapy: A resident with COPD, asthma, and SOB was observed multiple times without oxygen despite a physician order for 2L. Staff were unsure whether the order was continuous or PRN, and the resident reported staff were checking her O2 level and deciding whether to apply oxygen, while the oxygen concentrator was seen in the room and later removed.
PRN Psychotropic Medication Order Lacked Required End Date: A resident with generalized anxiety disorder and mild major depressive disorder had a PRN Alprazolam order for anxiety that was written with an indefinite end date. The MAR showed the medication was administered multiple times, and the DON stated the order should have had a 14-day end date rather than no end date.
A resident had IV Daptomycin in her room with the bag and tubing unlabeled, and an LPN confirmed the missing date and time. In another room, a bottle of Nystatin powder labeled for a different resident was found on a dresser and was being used by a resident who had no current order for it. The DON confirmed the powder should not have been in that resident’s room, and the facility policy required IV tubing to be labeled and medications to be stored securely.
A resident did not receive prescribed medications for constipation, including Milk of Magnesia, a Bisacodyl suppository, and a disposable enema, as documented in the MAR. Staff interviews revealed a failure to follow physician orders and the facility's bowel elimination policy, resulting in the resident calling 911 due to constipation.
A facility failed to accurately document a resident's skin conditions in the MDS. The resident had wounds on her right leg and buttock, with physician orders for specific wound care. However, the MDS did not reflect these conditions. The MDS Coordinator noted the resident's non-healing diabetic ulcer, but a remote coder incorrectly coded the section. The DON stated the facility follows the RAI manual for the MDS process.
A facility failed to refer a resident diagnosed with bipolar disorder for a Level II PASARR evaluation. The resident's Level I PASARR did not indicate any mental illness, and there was no documentation of a referral for further evaluation. The DON confirmed the oversight, which was contrary to the facility's policy requiring PASARR screening as part of the assessment process.
The facility failed to adhere to professional standards for PICC line care and pain management. Two residents had PICC lines with transparent dressings over gauze, which were not changed within 24 hours as required. Additionally, a resident received Acetaminophen for pain levels exceeding the physician's prescribed parameters without consulting the physician. The facility's policies were not followed, leading to deficiencies in care.
The facility failed to store medications securely, as observed in several residents' rooms where medications like eye drops, antacids, Albuterol, and nasal spray were left unsecured. Staff interviews confirmed that these medications should not be at the bedside without proper orders and assessments, highlighting a breach in the facility's medication storage policy.
The facility failed to properly store and label food in the main and satellite kitchens. Observations revealed spoiled tomatoes, improperly covered boiled eggs, and unlabeled pureed food and ground beef patties. Additionally, raw shell eggs were stored above ready-to-eat products. The Kitchen Manager acknowledged these issues, which violated the facility's food safety policy.
A facility failed to ensure staff used PPE for a resident under isolation precautions for C. diff. A dietary aide entered the resident's room without PPE, despite signage indicating contact isolation. Interviews confirmed the oversight, and the facility's policy required gloves and a gown for such cases.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure that the staff member hired as Dietary Manager met the required qualifications for that position. During interview and record review, Staff A stated he was employed as the Dietary Manager and had worked in that role at the facility since September 2025. Review of his personnel record showed only a high school education, and there was no documentation that he had completed a course of study in food safety and management by no later than October 1, 2023. During interviews, Staff A stated he was not qualified as a Certified Dietary Manager and had no other certifications or credentials related to kitchen management. He confirmed he had obtained a high school diploma and had previously worked as a Dietary Manager in another state. The Administrator also confirmed that Staff A had not yet completed a course of study in food safety and management. The job description for Director of Dining and Nutrition Services required one of several specified qualifications, including certification or an appropriate degree, and noted that staff hired after November 28, 2016 were to meet those requirements within 1 year after that date.
Inaccurate MDS Did Not Reflect Depression Diagnosis
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident with behavioral health needs. The resident was admitted with diagnoses including major depressive disorder, and the admission record showed depression with an onset date of 2/20/2026. However, the admission MDS did not document depression under Section I, Active Diagnoses. The resident also had physician orders for Bupropion HCl ER 300 mg daily and Sertraline HCl 100 mg, 2 tablets daily, both ordered for depression, and the February 2026 MAR showed both medications were administered from 2/21/2026 through 2/28/2026. A psychiatry admission note identified the chief complaint as depression and documented a past neuropsychiatric history of dementia and depression. During interview, the MDS Coordinator stated the resident had a diagnosis of depression in the system as of 2/20/2026 and the MDS would need to be corrected. The DON stated the facility did not have a policy for MDS and followed the RAI.
PASRR Not Updated for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate PASRR for residents with newly evident or possible serious mental disorder for 3 of 7 residents reviewed. Resident #7 was admitted with diagnoses including delusional disorders, unspecified dementia with behavioral disturbance, and mild cognitive impairment. The initial Level I PASRR showed no diagnosis or suspicion of mental illness, but later progress notes documented increased agitation and delusions, and a later medication record listed quetiapine for delusional disorder. During interview, the Social Services Director stated the PASRR should have been updated after the resident’s behavior changed and psychotropic medication was warranted, and the APRN stated the resident had been seen seeing things that were not there and had been prescribed quetiapine for delusional symptoms. Resident #10 was admitted and readmitted with diagnoses including generalized anxiety disorder and major depressive disorder, yet the Level I PASRR documented no diagnosis or suspicion of serious mental illness or intellectual disability and indicated a Level II evaluation was not required. The DON stated the PASRR should have been updated to reflect those diagnoses. Resident #131 was admitted with diagnoses including cognitive communication deficit, dementia, major depressive disorder, and Alzheimer’s disease, but the PASRR again documented no diagnosis or suspicion of mental illness. The Social Services Director stated the PASRR needed to be corrected and explained that she had been reviewing them and sending them to the case manager for correction and follow-up paperwork.
Failure to Follow Wound, Weight, and Insulin Orders
Penalty
Summary
The facility failed to ensure a wound dressing was dated for a resident with a left shin skin tear. The resident had a physician order to cleanse the wound, apply xeroform, and cover it with a dry dressing daily. During two observations, the left shin wound was covered with a bandage that had no date on it. The ADON confirmed the dressing was undated, and an LPN stated the dressing had been changed but the date had been overlooked. Another LPN stated the dressing change had been completed without a date being placed on the dressing. The facility policy for clean dressing changes required the dressing to be secured with initials and date. The facility also failed to obtain physician-ordered daily weights for the same resident, who had CHF and an order for morning weights with notification to the physician for specified weight changes. The resident's weight record showed multiple missed dates with no weights documented. In addition, the facility failed to follow physician-ordered blood glucose parameters for another resident receiving Humalog sliding-scale insulin. The orders required specific actions based on blood sugar ranges, including carb replacement, rechecks, or calling the MD/NP for certain values. The MAR showed multiple blood glucose readings in ranges that required ordered interventions, including values above 300 mg/dL and one reading of 479 mg/dL.
Failure to Complete Ordered Weight Monitoring for Two Nutritionally At-Risk Residents
Penalty
Summary
The facility failed to monitor weights for two residents who were identified as nutritionally at risk. For Resident #63, physician orders directed daily weights on multiple occasions in February 2026, including daily weights for 3 days and later daily weights for 7 days, but the TAR showed missing entries and several weights were marked as not applicable. The weight summary documented weights of 111.4 pounds on 2/14/2026 and 104.4 pounds on 2/24/2026, with no other weights documented for February and March 2026. The nutrition assessment noted the resident was discussed at the NAR meeting and added to daily weights. For Resident #88, physician orders also directed daily weights for 3 days in February 2026 and again later in the month, but the TAR showed N/A entries and no documented weights for several ordered dates. The weight summary showed weights of 119.8 pounds on 2/17/2026, 113.8 pounds on 2/24/2026, 114.2 pounds on 3/3/2026, and 113.4 pounds on 3/4/2026, with no other weights documented for February and March 2026. The nutrition assessment stated the resident would be monitored for weight loss and signs and symptoms of malnutrition. During interview, an LPN stated the person assigned to do weights was sometimes unavailable, which was why weights were marked not applicable, and the DON stated the weights for both residents were not done and floor staff did not pick up on doing them.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure a resident received oxygen as ordered by the physician for Resident #106, who had COPD, asthma, and shortness of breath. On 3/2/2026 and 3/3/2026, observations showed the resident sitting in a wheelchair, participating in therapy, sitting up in bed, and later lying in bed without oxygen being administered. A portable oxygen concentrator was seen in the room on 3/2/2026, but the resident stated it was not hers and had been in the room when she first arrived. By 3/3/2026, the concentrator was no longer in the room. The resident stated staff would check her oxygen level on her finger and then decide whether to apply oxygen, and she said staff had taken the oxygen machine that morning because they could not decide if she needed oxygen. The physician order dated 2/24/2026 read, "Oxygen order 2L." An LPN stated the order was for 2 liters but did not know whether it was continuous or PRN, while an RN stated the order meant oxygen was to be continuously administered unless otherwise specified. The DON stated the order needed to specify whether oxygen was continuous or PRN and that nurses were expected to follow MD orders.
PRN Psychotropic Medication Order Lacked Required End Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for Resident #10 was free from unnecessary use because the order for Alprazolam 0.25 mg by mouth every 24 hours as needed for anxiety had an indefinite end date and did not include a limited duration. Resident #10 was admitted and later readmitted with diagnoses including generalized anxiety disorder and mild single episode major depressive disorder. Review of the physician order dated 2/23/2026 showed the Alprazolam order started on that date with no end date, and the MAR showed the medication was administered on 2/23/2026 at 1:41 PM, 2/28/2026 at 12:53 PM, and 3/3/2026 at 2:11 AM. During interview, the DON stated the Alprazolam order should have included an end date of 14 days from the start date and that an indefinite end date was not acceptable.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in 2 of 4 units. During an observation, a resident’s room contained an intravenous infusion bag of Daptomycin connected to IV tubing, and neither the bag nor the tubing was labeled with the date and time. An LPN confirmed the IV bag and tubing were not labeled, and the DON stated that IV tubing should be dated and changed every 24 hours. The facility policy for IV therapy required all IV tubing to be labeled with date, time, and initials. In a separate observation, a bottle of Nystatin 100,000 units powder was found on another resident’s dresser, but the bottle was labeled with a different resident’s name. The resident stated she used the powder for sweating under her breasts, while the DON confirmed the Nystatin should not have been in that resident’s room and used on her. An LPN stated the resident had no current order for Nystatin, and CNAs described using baby powder or notifying the nurse when the resident complained of sweating. The facility medication storage policy required all drugs and biologicals to be stored in locked compartments under proper security and control.
Failure to Administer Medications as Ordered for Constipation
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident who was admitted with diagnoses including muscle weakness and abnormalities of gait and mobility. The physician had prescribed Milk of Magnesia (MOM) to be given every 12 hours as needed for constipation if no bowel movement occurred for two days. However, the Medication Administration Record (MAR) showed no entries for the administration of MOM from the start date to the discontinuation date. Additionally, the resident was prescribed a Bisacodyl suppository and a disposable enema to be used if MOM was not effective, but there were also no entries for these medications on the MAR during the specified period. Interviews with staff revealed a lack of adherence to the physician's orders and the facility's bowel elimination policy. The resident had not received the prescribed MOM, suppository, or enema, leading to the resident calling 911 due to constipation. Staff members admitted to not following the bowel protocol and assuming that other shifts had administered the medications. The facility's policy required that the first line of intervention be given if no bowel movement occurred within 48 hours, followed by an enema if the first intervention was ineffective. However, these steps were not followed, and the resident did not receive the necessary treatment as ordered by the physician.
Inaccurate MDS Documentation for Resident with Skin Conditions
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident with skin conditions. During an observation, the resident was found with a tubular stretch net bandage and dressing on her right lower leg. The resident reported having wounds on her bottom and right leg upon admission. Physician orders dated prior to the MDS assessment indicated specific wound care instructions for both the right lower extremity and buttock wounds. However, the MDS, dated shortly after admission, did not document any skin conditions under Section M. The MDS Coordinator acknowledged that the resident was admitted with a non-healing diabetic ulcer, but a remote MDS coder incorrectly coded the section. The Director of Nursing stated that the facility follows the Resident Assessment Instrument (RAI) manual for the MDS process.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident diagnosed with a possible serious mental disorder was referred for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. Resident #38 was initially admitted with a diagnosis of other bipolar disorder, which was identified on January 2, 2024. However, the Level I PASARR completed on December 28, 2023, did not include any entries under mental illness or suspected mental illness. A review of the clinical records showed no documentation that the resident had been referred for a Level II PASARR evaluation following the diagnosis. During an interview, the Director of Nursing confirmed that the referral had not been made. The facility's policy on Behavioral Health Services, implemented on March 5, 2024, requires the completion of PASARR screening as part of the comprehensive assessment process to identify and assess a resident's mental and psychosocial status.
Deficiencies in PICC Line Care and Pain Management
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for residents with Peripherally Inserted Central Catheter (PICC) lines. Two residents with PICC lines had transparent dressings placed over gauze, which obscured the insertion site and were not changed within the required 24-hour period. The facility's policy did not specify that gauze should not be used under transparent dressings, and staff were unaware of the need to change the dressing within 24 hours when gauze was used. This oversight was confirmed by the Infection Prevention Officer and the Director of Nursing, who acknowledged the lack of awareness and policy clarity regarding dressing changes. Additionally, the facility did not adhere to professional standards for pain management for a resident. The resident received Acetaminophen for pain levels that exceeded the parameters set by the physician's order. The Medication Administration Record showed multiple instances where the medication was administered for pain levels higher than the prescribed range without consulting the physician for further orders. The Director of Nursing confirmed that the medication was given outside of the prescribed parameters and emphasized the expectation for staff to follow the physician's orders. The facility's policies on PICC line dressing changes and medication administration were not followed, leading to deficiencies in care. The PICC line dressing policy did not align with professional guidelines, and staff were not informed of the correct procedures. Similarly, the medication administration policy was not adhered to, resulting in the administration of pain medication outside the prescribed parameters. These deficiencies highlight a lack of adherence to professional standards and facility policies, impacting the quality of care provided to the residents.
Unsecured Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as evidenced by multiple observations of unsecured medications in residents' rooms. Resident #264 had a bottle of lubricant eye drops on her nightstand without a physician's order, and Resident #92 had an antacid tablet left on her table by a nurse, despite not having orders to self-administer medications. Similarly, Resident #266 had a vial of Albuterol left unsecured in his room, and Resident #212's Albuterol inhaler was repeatedly observed on the bedside table without being secured. Resident #213's nasal spray was also found unsecured, and the resident admitted to frequent use without proper assessment for self-administration. The facility's policy requires that all medications be stored in locked compartments unless a resident has been assessed and approved for self-administration, with medications then secured in a locked bedside table. However, observations revealed that medications were left unsecured in residents' rooms, contrary to the facility's policy. Interviews with staff, including the LPN and the Director of Nursing, confirmed that medications should not be at the bedside without proper orders and assessments. The facility's failure to adhere to its medication storage policy resulted in multiple instances of unsecured medications in residents' rooms.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in both the main and satellite kitchens, as observed during a survey. In the walk-in cooler, bulk raw tomatoes were found with black and white areas, indicating spoilage, and a large container of boiled eggs was partially covered. In the reach-in cooler, there was a container of pureed food and ground beef patties without identifying labels or dates, two open containers of whole milk without an open date, and a container of sour cream past its use-by date. Additionally, raw shell eggs were improperly stored directly over ready-to-eat/drink products like whole milk in the satellite kitchen reach-in cooler. During an interview, the Kitchen Manager acknowledged these deficiencies, stating that spoiled tomatoes should have been removed, the boiled egg container should have been sealed, and all food items should have been labeled and dated. The manager also confirmed that raw shell eggs should not be stored above ready-to-eat/drink products. The facility's policy on food safety, implemented in April 2024, requires proper labeling, dating, and storage of food to prevent contamination and deterioration, which was not adhered to in this instance.
Failure to Use PPE for Resident on Isolation Precautions
Penalty
Summary
The facility failed to ensure that staff used personal protective equipment (PPE) while providing services to a resident under isolation precautions for Clostridioides difficile (C. diff). During an observation, a dietary aide entered the resident's room without donning PPE, despite the presence of signage indicating contact isolation precautions. The resident had a physician order for contact precautions due to C. diff, and the facility's policy required staff to wear gloves and a gown upon entry into the room. Interviews with the dietary aide and the Director of Nursing confirmed the failure to adhere to the contact precaution protocols. The dietary aide acknowledged not using PPE and recognized the need to follow the posted precautions. The Director of Nursing stated that staff should use appropriate PPE for transmission-based precautions, including gown, gloves, and mask, and confirmed that the resident should have been under contact precautions while awaiting stool culture results. The facility's policy on managing C. diff infections emphasized the importance of wearing gloves and a gown when entering the resident's room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberridge Nursing & Rehabilitation Center | 5.8 mi | ★★★★★ | 8 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 9.5 mi | ★★★★★ | 16 | 0 |
| Life Care Center Of Ocala | 9.8 mi | ★★★★★ | 8 | 0 |
| Palm Garden Of Ocala | 9.9 mi | ★★★★★ | 1 | 0 |
| Avante At Ocala, Inc | 12 mi | ★★★★★ | 25 | 0 |
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