Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Bridgetown Nursing And Rehabilitation Centre during CMS and state inspections, most recent first.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when two CNAs provided incontinence care to a resident with severe cognitive deficits, bowel and bladder incontinence, and orders for EBP related to a gastrostomy tube and tracheostomy, without wearing required gowns during this high-contact care activity, despite the policy specifying gown and glove use for tasks such as changing briefs, providing hygiene, and device care.
Late MDS Assessments: The facility failed to complete and submit multiple resident MDS assessments in a timely manner. Records showed numerous annual, quarterly, admission, and discharge return anticipated assessments left in progress or incomplete, with overdue ARDs across residents with conditions such as dementia, epilepsy, CHF, COPD, ventilator dependence, diabetes, CKD, and bipolar disorder. An RN confirmed delays were related to staffing issues, competing duties, and prioritizing new admissions over quarterly and annual assessments.
Dirty resident rooms and bathrooms were observed for two residents. One resident with impaired cognition and extensive ADL dependence had a stained privacy curtain, soiled floor, debris under the bed, a heavily soiled bed frame and bedside table, and a dirty pillowcase. Another resident with bipolar disorder, obesity, DM, anxiety, GERD, and schizoaffective disorder had black and brown buildup in the bathroom, a smudged wall, and chipped, ragged flooring by the bed. A CNA confirmed the conditions, and policy required daily cleaning of resident rooms and bathrooms.
Failure to provide bed hold notification after hospital discharge. A cognitively intact resident with multiple medical diagnoses was discharged to the hospital and later returned, but the record had no documentation that a bed hold notice was given. The Administrator confirmed the facility did not provide bed hold notifications at discharge and instead used a monthly notice system; the resident's signed bed-hold policy showed 19 days remaining.
Inaccurate PASARR Screening: A resident admitted with multiple diagnoses, including PTSD, anxiety, and bipolar disorder, had an inaccurate PASARR screen that failed to identify the PTSD and anxiety diagnoses. The resident was cognitively intact and required varying levels of staff assistance with meds, hygiene, dressing, and toileting. The RN and Administrator in Training confirmed the PASARR screening was not completed accurately.
Incomplete comprehensive care plans were identified for three residents. One resident with dementia and impaired cognition had no care plan for those needs, another resident with PTSD and anxiety had no related care plan despite needing assistance with multiple ADLs, and a third resident with severe cognitive impairment and denture concerns had no dental needs addressed in the care plan. The DON and AIT confirmed the omissions.
Failure to Hold and Document Care Conferences and Update Care Plans: The facility did not ensure care conferences were provided or care plans revised as needed for two residents. One resident with bipolar disorder, DM, anxiety, GERD, schizoaffective disorder, and an AKA reported a fall/slide from bed, but the fall care plan was not updated with the identified intervention. Another resident with COPD, recurrent major depression, parkinsonism, bipolar disorder, and severely impaired cognition had no documentation of quarterly care conferences; the resident said staff did not ask about care goals, and SS confirmed no care conference notes were present.
Failure to ensure a resident wore an ordered left resting hand splint. A resident with severe cognitive impairment and occasional refusal of care was ordered to wear the splint in the A.M. with skin checks every shift, but repeated observations showed the splint was not on. An AIT and an LPN verified the splint was off, and the LPN stated the resident frequently removed it and staff did not document when it was removed or reapplied.
A resident with multiple health conditions experienced a change in anticoagulant medication from Coumadin to Eliquis due to monitoring issues. The facility failed to notify the resident's legal representative of this significant change in treatment, as confirmed by staff and family interviews. This oversight was contrary to the facility's policy requiring notification of such changes.
The facility failed to complete comprehensive care plans for two residents, one with a Stage II pressure injury and another with a physician's order for moisture barrier cream, as confirmed by medical record reviews, observations, and staff interviews.
A facility failed to follow infection control procedures during a dressing change for a resident with multiple diagnoses. An LPN did not perform hand hygiene or change gloves when transitioning from a dirty wound area to a clean dressing, violating CDC guidelines and the facility's infection control policy.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP). Resident #17 was admitted on 03/11/25 with diagnoses including acute respiratory failure, depression, anxiety, a history of infectious and parasitic diseases, and gastrostomy status. A Minimum Data Set (MDS) assessment dated 12/16/25 documented that the resident had severe cognitive deficits, required substantial assistance with activities of daily living, and was incontinent of bowel and bladder. Physician orders dated 03/12/25 directed that the resident be placed on EBP related to the gastrostomy tube and tracheostomy. On 03/02/26 at 1:18 P.M., surveyors observed two CNAs providing incontinence care to Resident #17 without wearing gowns, despite the resident being on EBP. Both CNAs confirmed during interviews that they had not worn gowns while providing this care and acknowledged that they should have worn gowns because the resident was on EBP. Review of the facility’s Enhanced Barrier Precautions policy dated 05/2024 showed that EBP is an infection control intervention using targeted gown and glove use during high-contact resident care activities, which include changing briefs, assisting with toileting, providing hygiene, and device care such as feeding tubes and tracheostomy tubes. The observed incontinence care fell under these high-contact activities, but the required gown use was not followed.
Late MDS Assessments
Penalty
Summary
The facility failed to ensure resident assessments were completed in a timely manner for 17 of 17 residents reviewed for resident assessments. The report states that multiple MDS assessments were left in progress and not submitted, with several showing overdue ARDs for quarterly, annual, admission, discharge return anticipated, and entry assessments. The census was 41, and the deficiency was identified through record review, staff interview, and policy review. Resident records showed repeated delays across a wide range of residents with significant medical histories, including dementia, epilepsy, chronic respiratory failure with ventilator dependence, heart failure, COPD, diabetes, Parkinsonism, cerebral palsy, intellectual disabilities, kidney disease, depression, bipolar disorder, and cancer diagnoses. Examples included residents whose annual or quarterly MDS assessments remained in progress, were incomplete, or were not submitted, with red-letter notes indicating ARDs were overdue by 19 to 69 days. Several residents also had assessments for discharge return anticipated or entry that remained in progress. During interview, the RN confirmed there were multiple late MDS assessments due to staffing issues while she was performing MDS duties, training staff, handling infection control, and serving as acting DON starting 07/01/25. She stated some MDSs were completed on paper and not entered into the electronic record, and that she could not do everything at once, so she prioritized new admissions over quarterly and annual assessments. The facility policy reviewed stated that all MDS assessments were to be completed, electronically encoded into the MDS system, and transmitted to CMS IQIES in accordance with OBRA regulations.
Dirty resident rooms and bathrooms observed in two rooms
Penalty
Summary
Resident #05 was admitted with diagnoses including bipolar disorder, obesity, DM, anxiety disorder, GERD, and schizoaffective disorder. Her MDS showed she was cognitively intact and dependent on staff for medication administration, with set-up assistance needed for meals, oral hygiene, toilet use, dressing, and personal hygiene. Observation of her room revealed an unknown fuzzy black and brown substance under the bathroom sink, a heavily soiled bathroom floor with black buildup, a long black smudge on the bathroom wall above the handrail, and chipped, ragged flooring alongside the bed with evidence that prior fall strips had been removed. A CNA confirmed these conditions during interview, and the facility policy stated that resident rooms and bathrooms are to be cleaned daily.
Failure to Provide Bed Hold Notification After Hospital Discharge
Penalty
Summary
The facility failed to provide a bed hold notification to a resident upon discharge to the hospital. Resident #20 was admitted with diagnoses including sepsis, intestinal obstruction, cellulitis, acute kidney failure, lymphedema, absence of the left leg above the ankle, UTI, anemia, supraventricular tachycardia, and major depressive disorder. The most recent MDS showed the resident was cognitively intact, dependent on staff for medication administration and toilet use, required moderate assistance with bathing, dressing, personal hygiene, and toilet use, and needed set-up assistance with eating and oral hygiene. The resident was discharged to the hospital and later returned to the facility, but the medical record contained no documentation that a bed hold notice had been provided. During interview, the Administrator confirmed the facility does not provide residents with bed hold notifications upon discharge and instead gives residents a monthly note of bed hold status, meaning a resident discharged during the month would not receive notification until the end of the month. Review of the facility's Nursing and Rehabilitation Bed-Hold Policy showed the resident had 19 bed hold days remaining for 2025, and the policy was a fill-in-the-blank form for the resident to sign.
Inaccurate PASARR Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident. The resident was admitted with diagnoses including essential primary hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus, GERD, PTSD, anxiety, and bipolar disorder. A review of the MDS dated 04/10/25 showed the resident was cognitively intact and dependent on staff for medication administration, with set up assistance needed for meal set up, oral hygiene, and upper body dressing, and supervision needed for personal hygiene, bathing, and toilet use. Review of the PASARR notice dated 12/27/24 showed the facility failed to identify the resident’s PTSD and anxiety disorder. During interview on 09/04/25, the RN and Administrator in Training confirmed the facility failed to properly screen the resident and did not accurately identify the anxiety disorder and PTSD diagnoses.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were complete and accurate for three residents reviewed. For Resident #01, the medical record showed diagnoses including atrial fibrillation, sepsis, GERD, arthritis, vascular dementia, anxiety, CHF, COPD, asthma, and bipolar disorder, and the MDS indicated impaired cognition. Review of the care plans showed no plan of care for dementia or impaired cognition, and the DON confirmed the resident had a diagnosis of dementia and that no care plan had been developed for it. For Resident #03, the record showed diagnoses including hypertension, emphysema, interstitial pulmonary disease, traumatic arthropathy, chronic fatigue, diabetes mellitus, PTSD, anxiety, GERD, and bipolar disorder. The MDS showed the resident was cognitively intact and required varying levels of assistance with medication administration, meal setup, oral hygiene, dressing, bathing, personal hygiene, and toilet use. Review of the care plans showed no care plan related to PTSD or anxiety, and the DON confirmed the omission. For Resident #44, the record showed diagnoses including COPD, recurrent major depressive disorder, unspecified parkinsonism, and unspecified bipolar disorder, and the MDS showed severely impaired cognition with physical, verbal, and self-directed behaviors and occasional rejection of care. The resident stated she was edentulous with dentures and thought she needed a new set, dental services had seen her for denture concerns, and the care plan had no reference to dental needs; the AIT verified the comprehensive care plan was incomplete.
Failure to Hold and Document Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure residents were provided care conferences and that care plans were revised as needed. For Resident #05, medical record review showed admission with diagnoses including bipolar disorder, obesity, DM, anxiety disorder, GERD, and schizoaffective disorder. The resident’s MDS indicated she was cognitively intact and dependent on staff for medication administration, with set up assistance needed for meals, oral hygiene, toilet use, dressing, and personal hygiene. A progress note documented that she reported rolling out of bed and slipping when she attempted to stand, but no immediate intervention was listed in the note. Her fall care plan, dated 04/18/24, identified her as at risk for falls related to above-the-knee amputation, medication regimen, and comorbidities, with interventions including following fall protocol and therapy as ordered. For Resident #44, record review showed diagnoses including COPD, recurrent major depressive disorder, unspecified parkinsonism, and unspecified bipolar disorder. The most recent MDS indicated severely impaired cognition, physical, verbal, and self-directed behaviors, no wandering, and occasional rejection of care. The medical record contained no documentation of quarterly care conferences. The resident stated she did not have regular care conferences and staff did not ask her what her care goals were. Social Services verified there were no notes for care conferences with the resident or family and stated care conferences were held when indicated on the MDS, but were not documented. The facility policy stated residents were to be informed of their right to participate in treatment planning and given advance notice of care planning conferences, or an explanation documented if participation was not practicable.
Failure to Ensure Ordered Hand Splint Was Worn
Penalty
Summary
The facility failed to ensure a resident with physician-ordered splint use was wearing the ordered left resting hand splint. Resident #16 was admitted with diagnoses including peripheral vascular disease and supraventricular tachycardia, had severe cognitive impairment on MDS assessment, and occasionally refused care. A physician order dated 05/25/25 directed that the left resting hand splint be applied in the A.M. and that skin integrity be checked every shift. The care plan dated 06/05/25 also directed staff to check the skin every shift upon donning and doffing for signs and symptoms of skin breakdown, but it did not indicate refusal of care. Observations on 09/02/25 at 9:30 A.M., 11:00 A.M., and 3:01 P.M., and again on 09/03/25 at 10:43 A.M., showed the resident did not have the left hand splint on. During interview on 09/03/25, the AIT and LPN verified the splint was not on the resident, and the LPN stated the night shift put it on but the resident frequently removed it. The LPN also verified staff did not document when the resident removed the splint or when it was reapplied.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify the legal representative of a significant change in the care and treatment of a resident. The resident, who was admitted with multiple health conditions including a prosthetic heart valve, cerebral infarction with left-sided hemiplegia and hemiparesis, vascular dementia, atrial fibrillation, and obesity, experienced a change in medication. The physician changed the resident's anticoagulant from Coumadin to Eliquis due to issues with obtaining necessary blood draws and PT-INR results for monitoring Coumadin dosing. However, there was no documentation in the progress notes indicating that the resident's representative was informed of this medication change. Interviews with facility staff and the resident's family confirmed that the representative was not notified of the medication change until nearly a month later. The facility's policy requires notification of the resident, their physician, and their family member or legal representative when there is a change in treatment. Despite this policy, the facility did not inform the resident's representative of the change from Coumadin to Eliquis, which was a significant alteration in the resident's treatment plan.
Failure to Complete Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, which was identified during a review of medical records, observations, and staff interviews. Resident #14, who was admitted with multiple diagnoses including breast cancer, kidney failure, atrial fibrillation, and acute cystitis, did not have a care plan addressing skin integrity and a Stage II pressure injury. This was confirmed during an observation of wound care and an interview with the Wound Care Physician and the MDS Coordinator, who acknowledged the absence of a care plan for the resident's skin concerns. Similarly, Resident #15, admitted with diagnoses such as depression, pain, chronic kidney disease, anxiety, and a history of skin cancer, also lacked a care plan related to skin integrity. Despite a physician's order for the application of moisture barrier cream after each incontinent episode, there was no corresponding care plan. This deficiency was verified through an interview with the MDS Coordinator, who confirmed that the care plan should have addressed the resident's skin integrity and risk for skin concerns.
Failure to Follow Infection Control Procedures During Dressing Change
Penalty
Summary
The facility failed to follow infection control procedures during a dressing change for a resident with multiple diagnoses, including breast cancer, kidney failure, atrial fibrillation, and acute cystitis. During an observation, an LPN removed a soiled incontinence brief and replaced it with a clean one, then cleansed an open wound on the resident's right buttock with saline and gauze. The LPN then placed a new wound dressing without performing hand hygiene or changing gloves, which is against CDC guidelines and the facility's infection control policy. An interview with the LPN confirmed that she did not complete any hand hygiene or change her gloves when transitioning from a dirty wound area to a clean dressing. The facility's Infection Prevention and Control Program, dated 10/01/23, mandates that hand hygiene should be performed in accordance with established procedures. This deficiency was identified during a complaint investigation and represents non-compliance with infection control standards.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| Hillebrand Nursing And Rehabilitation Center | 0 mi | ★★★★★ | 16 | 0 |
| Terrace View Gardens | 0.9 mi | ★★★★★ | 6 | 0 |
| Covenant Village Care Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Aventura At West Park | 2.3 mi | ★★★★★ | 5 | 0 |
| Edith Lane Of Cincinnati | 2.4 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.