Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Bridgeport Healthcare Center during CMS and state inspections, most recent first.
Dirty air conditioner/heater filters were observed in three of eight resident rooms, including rooms 202, 204, and 206. During a walk-through, the surveyor noted about one-quarter inch of dust on the filters, and an LPN later verified the filters were covered with a dust layer.
The facility failed to coordinate MDS diagnoses with PASARR findings for two residents. One resident had major depressive disorder and vascular dementia, but the PASARR marked no major mental illness; another resident had epilepsy, anxiety, major depressive disorder, and later bipolar disorder, while the PASARR did not reflect any mental illnesses even though the MDS marked seizure disorder, anxiety disorder, and bipolar disorder.
A resident with a fall care plan did not have the documented fall interventions in place. The plan called for non-skid socks and non-skid strips on the left side of the bed, but surveyors observed that the socks were not on while the resident was in bed and the strips were not present. An LPN confirmed the findings.
A resident was found to be receiving Pantoprazole 40 mg BID despite a pharmacist recommendation to change it to once daily before food. The recommendation had no physician response or signature, and the MAR showed the medication continued BID without change until the order was later updated. The DON stated the physician prescriber should have reviewed the order and that the pharmacist recommendation was missed.
The facility did not submit a required Five-Day Follow-Up Investigation report to the appropriate agencies after an initial allegation of abuse, neglect, or theft. Documentation confirming the report's submission was missing, and the relevant agency did not have the follow-up on file.
The facility failed to provide timely RSV immunization and education to residents, as recommended by the CDC, affecting multiple residents. Several residents tested positive for RSV, experiencing symptoms like chest congestion and shortness of breath, requiring oxygen therapy and isolation. The lack of timely immunization and education potentially exacerbated the outbreak and severity of symptoms.
The facility failed to maintain a clean and sanitary kitchen and dish room, with debris and dirt found in the walk-in freezer and refrigerator, food spillage in the reach-in refrigerator, and disrepair in the dish room floor. The Dietary Manager confirmed these issues, noting that a cleaning schedule had not been implemented. A follow-up tour found old food debris in the steam table, and the Executive Director revealed that a quote for floor repairs had been obtained but no further action was taken.
The facility did not post information about State agencies and advocacy groups in an accessible manner for residents, particularly those in wheelchairs. A resident confirmed the postings were too high to read, and the Administrator acknowledged this issue.
A facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) for a resident discharged after her last covered day of Medicare Part A services. The resident did not receive the NOMNC at least two days before the end of services, as required. The Director of Rehab confirmed the resident was ready for discharge, and the Business Office Manager acknowledged the lack of evidence for the NOMNC issuance.
A facility failed to maintain a homelike environment for a resident, as observed in room 205. The bathroom door had multiple scrapes and scratches, and the wall near the sink had rough, uneven patches from plastered nail holes. The Director of Maintenance acknowledged these issues, noting the wall was visible from the hallway and the room was scheduled for painting. The need to replace the bathroom door had been identified.
A facility failed to notify the long-term care Ombudsman of a resident's transfer to the hospital. While the resident and their representative received a written notice with necessary details, there was no documentation of Ombudsman notification. The Administrator confirmed the lack of evidence for this notification.
A facility failed to update the PASARR for a resident who was diagnosed with Major Depressive Disorder after admission. The oversight was confirmed during an interview with the Admissions Director and Executive Director, revealing a lack of coordination with the State-designated authority to ensure appropriate care and services.
A resident's communication abilities declined due to the facility's failure to address a broken hearing aid. Despite the hearing aid being turned in nearly a month prior, no action was taken to repair or replace it, and the resident's care plan lacked information on hearing aid use. The facility did not schedule follow-up appointments or services to address the issue, violating their grievance policy of resolving issues within five business days.
A resident's broken hearing aid was not addressed in a timely manner, despite being in the facility's possession for nearly a month. The facility's grievance policy was not followed, as no actions or interventions were documented to resolve the issue, leading to a deficiency.
A facility failed to adhere to a physician's order for oxygen administration, providing a resident with 4.5 LPM instead of the prescribed 2 LPM for continuous use. This discrepancy was observed and confirmed by an LPN, who then corrected the oxygen flow.
A facility failed to follow a resident's dialysis care plan by taking blood pressure from the left arm, which had an AV fistula, on 74 occasions despite orders not to do so. The care plan and physician's orders were not adhered to, and there was no signage in the resident's room to indicate the restriction. The DON acknowledged the oversight, noting the fistula was non-functional and should not have been documented as working.
A resident with severe cognitive deficits eloped from a facility due to a dysfunctional magnetic lock on French doors leading outside. The doors, which lacked a wander guard alarm, were left open, allowing the resident to exit without triggering an alarm. Staff interviews revealed the lock system incorrectly indicated the doors were secure, posing a significant risk to residents.
Dirty HVAC Filters in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, homelike environment in three of eight observed resident rooms, identified as rooms 202, 204, and 206. During an initial walk-through on 04/06/26 at 1:00 PM, the surveyor observed that the air conditioner/heater filters in these rooms were dirty and had approximately one-quarter inch of dust on them. The surveyor then went to the nursing station closest to the resident rooms and asked LPN #36 to accompany her to the rooms for observation of the air filters. At 1:30 PM on 04/06/26, LPN #36 verified that the filters were covered with a dust layer.
MDS and PASARR Diagnoses Were Not Coordinated
Penalty
Summary
The facility failed to coordinate diagnoses on the MDS with the PASARR for two residents reviewed during the survey. One resident was admitted with major depressive disorder and vascular dementia and was prescribed sertraline, but the most recent PASARR completed by the facility marked the resident as having no major mental illness or suspected mental illness. Another resident was admitted with epilepsy, anxiety, and major depressive disorder, was later diagnosed with bipolar disorder during the stay, and had a PASARR completed at another nursing home that did not reflect any mental illnesses, with no current diagnosis marked and a primary diagnosis listed as N/A. The most recent MDS for this resident marked seizure disorder or epilepsy, anxiety disorder, and bipolar disorder as present and depression as absent. These discrepancies were reviewed with the Nursing Home Administrator.
Fall Interventions Not In Place for a Resident
Penalty
Summary
The facility failed to maintain an accident-free environment for Resident #39 in relation to fall interventions. Medical record review showed the resident had a care plan for falls that called for non-skid socks and non-skid strips to the left side of the bed. During observation, those fall interventions were not in place as documented in the care plan: non-skid socks were not on when the resident was in bed, and non-skid strips to the left side of the bed were not present. This was confirmed by an LPN during the survey.
Unnecessary Medication Regimen Not Addressed
Penalty
Summary
Resident #14 was found to have a current physician order for Pantoprazole 40 mg twice daily, and record review showed a pharmacist recommendation dated 07/18/25 noting that the resident had been receiving the proton pump inhibitor Pantoprazole 40 mg two times a day and recommending a change to once daily before food. The recommendation form had no physician response and no signature. Review of the MAR showed the resident continued to receive Pantoprazole scheduled twice daily without a change from the 07/18/25 order through 04/07/26. During interview, the DON stated the Pantoprazole order should have been reviewed by the physician prescriber and that the pharmacist recommendation was missed on 07/18/25.
Failure to Submit Required Five-Day Follow-Up Investigation Report
Penalty
Summary
The facility failed to submit a required Five-Day Follow-Up Investigation report to the appropriate agencies after an initial report of alleged abuse, neglect, or theft. During record review, it was found that fax confirmation sheets for the Five-Day Follow-Up Investigation, related to a previously reported incident, were missing. The Administrator confirmed the absence of these records and was unable to provide evidence that the follow-up report had been sent. Additionally, the state surveyor verified with the Office of Health Facility Licensure and Certification (OHFLAC) that the follow-up investigation was not on file. No further documentation was provided to demonstrate compliance with the reporting requirement.
Failure to Provide RSV Immunization and Education
Penalty
Summary
The facility failed to provide information and offer the Respiratory Syncytial Virus (RSV) immunization to residents in a timely manner, as recommended by the CDC. This deficiency affected multiple residents, including those identified as #3, #6, #7, #29, #33, #36, #37, #45, and #46, within a facility census of 60. The Infection Preventionist confirmed that residents had not been provided with educational information about the RSV vaccine's risks and benefits, nor had the vaccine been offered during the Fall immunization period of 2023. Several residents tested positive for RSV, with symptoms ranging from chest congestion, diminished lung sounds, and shortness of breath, to more severe conditions requiring oxygen therapy and isolation. For instance, Resident #3 tested positive for RSV and experienced bilateral chest congestion and diminished lung sounds, requiring oxygen therapy and nebulizer treatments. Similarly, Resident #6 showed symptoms of shortness of breath and hypoxia, necessitating oxygen therapy and medication adjustments. The lack of timely immunization and education on RSV vaccination contributed to the spread and severity of RSV among residents. Resident #7, for example, tested positive for RSV and experienced a decline in health, including poor oral intake and pneumonia. The facility's failure to offer the RSV vaccine and educate residents about it potentially exacerbated the outbreak and the severity of symptoms experienced by the residents.
Sanitation and Maintenance Deficiencies in Kitchen and Dish Room
Penalty
Summary
The facility was found to have several sanitation and maintenance deficiencies in its kitchen and dish room, which could potentially affect all residents receiving nutrition from the kitchen. During an initial tour, surveyors observed debris and dirt on the floors of the walk-in freezer and refrigerator, as well as food spillage inside and outside the reach-in refrigerator. The dish room floor had multiple missing tiles with brown and black substances, and a black substance was noted on the walls around the dish machine. These issues were confirmed by the Dietary Manager, who acknowledged that a cleaning schedule provided by a corporate representative had not yet been implemented. The dish room floor had been in disrepair since the Dietary Manager took over three months prior. A follow-up tour revealed old food debris in the steam table, which was confirmed by both the Dietary Manager and the corporate dietary manager as needing cleaning and sanitization. The Executive Director disclosed that a quote for repairing the dish room floor had been obtained in August, but no further action had been taken, and no additional documentation was provided. These observations and interviews highlight the facility's failure to maintain a clean and sanitary environment in the kitchen and dish room, as required by professional standards.
Inaccessible Posting of State Agency Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups in a manner that was accessible and understandable to residents. During an observation, it was found that the required postings were placed high on the wall, making them difficult to read for residents in wheelchairs. This was confirmed during an interview with a resident who expressed difficulty in seeing the postings from her wheelchair. The facility's Administrator acknowledged that the postings were too high for wheelchair-bound residents to read.
Failure to Issue Timely NOMNC
Penalty
Summary
The facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued in a timely manner for one of the residents reviewed for beneficiary protection notification. Specifically, Resident #22, who was discharged to home after her last covered day of Medicare Part A services, did not receive the NOMNC as required. The last covered day for Resident #22 was on 04/05/24, but the facility could not produce evidence that the NOMNC was delivered at least two calendar days before the end of Medicare-covered services, as mandated by the CMS-10123 form instructions. The Director of Rehab confirmed that the resident had met her therapy goals and was ready for discharge, while the Business Office Manager acknowledged the lack of evidence for the issuance of the NOMNC prior to the resident's discharge.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment. During an observation, it was noted that the lower section of the bathroom door in room 205 had multiple scrapes and scratches. Additionally, the wall to the right of the sink in the same room had four nail holes that had been plastered over, leaving uneven, rough splotches in the shape of a bow tie approximately two feet wide. The Director of Maintenance acknowledged that the patched wall was visible from the hallway and did not provide a homelike environment. The wall had been patched four to five months prior when an old towel rack was removed, and the room was on the list to be painted. The need to replace the bathroom door had been identified, and a new order was to be placed.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to the long-term care Ombudsman for a resident who was transferred to the hospital. During the medical record review, it was found that the resident and their representative received a written notice detailing the reason for transfer, the effective date, the new location, and the resident's appeal rights. However, there was no documentation in the electronic medical record indicating that the Ombudsman had been notified of the transfer. The facility's Administrator confirmed during an interview that they could not provide evidence of such notification.
Failure to Update PASARR for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate with the State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. This deficiency was identified during a survey process for one of the three residents reviewed. Specifically, a record review revealed that a resident was admitted to the facility without a diagnosis of a Level II mental illness. However, the resident was later diagnosed with Major Depressive Disorder, and the Pre-Admission Screening and Resident Review (PASARR) was not updated to reflect this new diagnosis. During an interview, the Admissions Director and the Executive Director confirmed that the PASARR had not been revised to include the new diagnosis.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to provide proper care and treatment to prevent a decline in a resident's communication abilities. During an initial screening, a resident indicated that he was unable to converse because his hearing aid was broken. Further investigation revealed that the broken hearing aid had been turned into the nursing staff nearly a month prior, but no action had been taken to repair or replace it. The resident's care plan did not include any information regarding the use of a hearing aid, indicating a lack of attention to the resident's communication needs. Interviews and record reviews showed that the facility had not scheduled any follow-up appointments or services to address the resident's hearing aid issue. Despite having documentation of a past audiology appointment, there were no new orders or plans to ensure the resident's communication abilities were maintained or improved. The facility's grievance policy, which states grievances should be resolved within five business days, was not adhered to in this case, as the issue remained unresolved for an extended period.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and assistive devices to maintain his hearing abilities. During an initial screening, the resident indicated that he could not converse because his hearing aid was broken. The hearing aid had been turned into the nursing staff nearly a month prior, but no actions were documented to address the issue. The facility's grievance policy states that grievances should be resolved within five business days, yet there were no notes or interventions recorded regarding the resident's hearing aid. Interviews with facility staff revealed that the resident had attended an audiology appointment, but no new orders were given, and a follow-up was scheduled for the following year. Despite the broken hearing aid being in the facility's possession, there was no documentation of any attempts to repair it until after the surveyor's inquiry. The lack of timely action and documentation regarding the resident's hearing aid needs led to the deficiency identified in the report.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to deliver respiratory care services consistent with professional standards of practice by not following the physician's order for oxygen administration for a resident. The resident was observed receiving oxygen at 4.5 Liters Per Minute (LPM) via nasal cannula, despite the physician's order specifying oxygen at 2 LPM, continuous, for shortness of breath. This discrepancy was confirmed during an interview with an LPN, who acknowledged the incorrect oxygen level and adjusted it accordingly.
Failure to Follow Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident by not adhering to the physician's orders and care plan instructions. The resident had an AV fistula in the left arm, and the care plan explicitly stated that no blood pressure (BP) should be taken from that arm. Despite this, records showed that the resident's BP was taken from the left arm on 74 occasions between May and October. Additionally, there was no signage in the resident's room to indicate the presence of the AV fistula and the restriction on taking BP from the left arm. Upon investigation, it was revealed that the order to avoid taking BP from the left arm did not originate from the dialysis center or neurologist, as the resident's fistula was non-functional and would not be used for dialysis. The Director of Nursing acknowledged that the orders and care plan should have been followed, and the nursing staff should not have documented the AV fistula as functioning. This oversight indicates a failure to follow professional standards of practice in providing dialysis care to the resident.
Dysfunctional Door Lock Leads to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe environment for its residents by having a dysfunctional magnetic lock on the French doors leading to the outside through the activities office. This malfunction exposed residents to potential hazards, as the doors could be opened without triggering an alarm, which is supposed to alert staff to unauthorized exits. The issue was identified when a resident with severe cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, managed to elope from the facility. The resident was found outside by an EMS team and was unable to explain how she exited the building. The resident involved in the incident had been admitted for long-term care due to dementia, which rendered her family unable to provide adequate care. On the day of the elopement, the door leading into the activities office from the residents' hallway was left open, allowing the resident access to the French doors. These doors were not locked and lacked a wander guard alarm, which would have been crucial in preventing the resident from leaving the facility unsupervised. Interviews with the facility's staff, including the Administrator and the Maintenance Director, revealed that the magnetic lock system on the French doors was faulty. The system incorrectly indicated that the doors were locked even when they were not, due to a gap between the magnets. This failure in the locking mechanism, combined with the absence of a wander guard alarm, created a significant risk for residents, particularly those identified as wanderers, of which there were seven in the facility at the time.
Removal Plan
- Resident #58 was returned to the center and was re-assessed by the licensed nurse with no injuries identified.
- An updated wandering observation tool, pain observation tool, and fall risk observation tool were completed by the licensed nurse.
- Family and provider were notified.
- A full-scale elopement drill was completed with headcount with no additional concerns identified.
- The event was reported to OHFLAC.
- Signage was placed on the doors to ensure the staff made sure the door was fully secure.
- Three additional elopement drills were completed with staff education to validate staff response.
- All-staff education was started to include: Door is to be closed all the way so magnetic lock engaged. The door deadbolt is to be locked when no one is present in activities. Door is not to be used as an exit/egress by staff. Activities office door is to remain closed at all times unless there is a staff member in the activities room.
- A deadbolt lock was installed on the door.
- An activities aide/designated staff member was placed at the French doors in the activities room to monitor the doors with instruction that no one was to use the courtyard door to enter or exit the building as unintended egress.
- A keyed deadbolt was added to the Activities' French doors by the center maintenance director, verified by the Mobile ED to be securely closed to prevent residents from exiting the facility without supervision.
- A supplemental door open alarm was placed on the French doors, and verified to be functioning correctly by the center maintenance director.
- The activities aide/designated staff member is assigned to monitor the activities French doors until a self-closure device is installed on the door and to ensure the door appropriately closes and the maglock engages, with verification to be working appropriately by maintenance director.
- The supplemental door open alarm will remain in place until it is established that the magnetic lock on the French doors is correctly functioning with a self-closure device by the center maintenance director.
- If the magnetic lock cannot be repaired to manufacturer specifications it will be replaced and the supplemental door open alarm will remain in place until that time.
- An audit of all facility exiting doors was conducted to ensure all doors were securely latched, opening alarms were functioning properly and that self-closure devices are properly functioning with no additional findings of concern.
- An elopement drill was conducted by the center maintenance director and no additional concerns were noted.
- All staff present in the building are immediately being re-educated to not use the activities French doors to enter and exit the building and that the door will only be used for center specific activities when activities/designated staff are present for the duration of the activity with a door monitor assigned.
- All-staff not present will be educated upon return to work.
- Daily, maintenance will perform an audit to ensure all exit door self-closers and their magnetic locking components are working correctly and that the door is secured.
- The center maintenance director will immediately report findings of concern to the center administrator.
- Results of audits will be reported in the monthly Quality Assurance and Process Improvement meeting by the Center Maintenance Director for follow-up and in servicing needs to ensure compliance.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Bridgeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| United Transitional Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Maplewood Healthcare Center | 2.9 mi | ★★★★★ | 8 | 0 |
| River Oaks Healthcare Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Clarksburg Healthcare Center | 6.3 mi | ★★★★★ | 17 | 0 |
| St. Barbara's Memorial Nursing Home | 11.1 mi | ★★★★★ | 8 | 0 |
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