Bridgeway Pointe

Based on medical record review and staff interview, the facility failed to ensure a physician made a pre-determination of necessity for admission to a secured memory care unit prior to resident admission. This affected one (Resident #69) of five residents sampled. The facility census was 68 residents.

Findings include:

Review of the medical record review for Resident #69 revealed an admission date of 12/26/24 with diagnoses including Alzheimer's disease, atrial fibrillation, and hypertension.

Review of the medical record for Resident #69 revealed the resident resided in the secured memory care unit. Further review of the medical record for Resident #69 revealed there was no physician's order or determination per a physician indicating the resident was appropriate for admission to the secured unit.

Interview on 08/04/25 at 11:58 A.M. with Clinical Nurse Supervisor (CNS) #201 confirmed there was no physician's order or determination for Resident #69 to be admitted into the secured memory care unit.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure personal care services were provided as ordered. This affected one (Resident #74) of five residents reviewed. The facility census was 68 residents.

Findings include:

Review of the medical record for Resident #74 revealed an admission date of 08/16/23 with diagnoses including hypertension, anxiety, and dementia.

Review of the medical record for Resident #74 revealed a physician's order dated 04/25/25 to cleanse the right heel with wound cleanser, apply Medihoney, and apply a foam dressing twice a day per facility staff.

Review of the Treatment Administration Record (TAR) for Resident #74 dated April 2025 revealed the treatment to the resident's right heel was not signed off as completed on the first shift for the following dates: 04/26/25, 04/27/25, 04/28/25, 04/29/25, 04/30/25. The treatment was not signed off as completed on the second shift for the following dates: 04/28/25, 04/29/25, 04/30/25.

Review of the TAR for Resident #74 dated May 2025 revealed the treatment to the resident's right heel was not signed off as completed on the first shift for the entire month of May 2025. The treatment was not signed off as completed for the second shift on the following dates: 05/03/25, 05/04/25, 05/05/25, 05/07/25, 05/08/25, 05/09/25, 05/12/25, 05/13/25, 05/14/25, 05/21/25, 05/24/25, 05/26/25.

Review of the TAR for Resident #74 dated June 2025 revealed the treatment to the resident's right heel was not signed off as completed for the first shift for the entire month of June 2025.

Review of the TAR for Resident #74 dated July 2025 revealed the treatment to the resident's right heel was not signed off as completed for the first shift on the following dates: 07/01/25, 07/02/25, 07/03/25, 07/04/25, 07/05/25, 07/06/25, 07/10/25, 07/11/25, 07/12/25, 07/13/25, 07/14/25, 07/19/25, 07/20/25, 07/21/25, 07/24/25, 07/27/25, 07/28/25. The treatment was not signed off as completed for the second shift on 07/27/25 and 07/28/25.

Interview on 08/04/25 at 1:37 P.M. with Clinical Nurse Supervisor (CNS) #201 confirmed there was missing documentation of completion from Resident #74's TARs in April, May, June, and July 2025, and the facility could not be sure the treatment had been completed as ordered.

Review of the facility policy titled Simple Dressing dated 09/06/24 revealed the facility would ensure simple dressings were applied appropriately and wounds are monitored.

Based on medical record review and staff interview, the facility failed to ensure coordination and documentation of care with hospice services. This affected one (Resident #74) of five residents reviewed. The facility census was 68 residents.

Findings include:

Review of the medical record for Resident #74 revealed an admission date of 08/16/23 with diagnoses including hypertension, anxiety, and dementia.

Review of the progress note for Resident #74 dated 03/14/25 revealed the resident was admitted to hospice services on 03/14/25 for senile dementia of the brain.

Review of the physician's orders for Resident #74 revealed an order dated 03/28/25 to cleanse the resident's right heel with wound cleanser, pat dry, apply skin prep, and apply a foam dressing two times a week per the facility nurse and one time a week from the hospice nurse. The hospice nurse was to obtain measurements of the resident's wound weekly.

Further review of medical records for Resident #74 revealed it did not include weekly measurements of the resident's wound, nor did the record include an evaluation at least once every seven days to determine whether the resident should be transferred to a nursing home or other appropriate health care setting.

Interview on 08/04/25 at 11:56 A.M. with Clinical Nurse Supervisor (CNS) #201 confirmed the facility had not ensured Resident #74's wound was measured weekly and the facility had not documented a weekly evaluation of the resident's condition to determine if the resident should be transferred to a nursing home or other appropriate health care setting.

Based on review of the facility fire drill records and staff interview, the facility failed to ensure residents were evacuated during fire drills as required. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Findings include:

Review of the facility fire drill records dated August 2024 to July 2025 revealed it did not include documentation of resident evacuations during fire drills.

Interview on 07/30/25 at 2:51 PM with Clinical Nurse Supervisor (CNS) #201 confirmed residents were not evacuated during any of the fire drills dated August 2024 to July 2025.

Based on review of the facility disaster preparedness drill records and staff interview, the facility failed to ensure two disaster preparedness drills were conducted annually as required. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents.

Findings include:

Review of the facility disaster preparedness drill records dated August 2024 to July 2025 revealed the facility conducted a tornado drill on 05/21/25. The facility had not conducted an additional disaster preparedness drill from August 2024 to July 2025.

Interview on 07/30/25 at 2:04 P.M. with Clinical Nurse Supervisor (CNS) #201 confirmed the facility conducted only one disaster preparedness drill from August 2024 to July 2025.

Based on observation, staff and resident interviews, the facility failed to ensure activities were provided for the residents housed in the Memory Care Unit (MCU). This affected 17 (#15, #30, #32, #33, #34, #41, #48, #52, #58, #62, #65, #67, #68, #69, #70, #71, and #72) residents out of 17 resident who resided on the MCU. The facility census was 73.

Findings included:

Observation of a chalk board in the MCU on 03/26/24 at 8:20 A.M. revealed from 9:30 A.M. to 2:00 P.M., the activities listed included eating, toileting, sitting in recliners, and other activities of daily living (ADLs).

Observation of the MCU on 03/26/24 at 8:23 A.M. revealed the residents were out of bed and sitting in recliners or at the table eating breakfast. Observations from 9:15 A.M. to 9:56 A.M. revealed the residents were sitting in the common area and there were no activities being conducted. Observation at 10:55 A.M. revealed the residents were sitting in the recliners while the State Tested Nursing Aide (STNA) #100 was on her personal phone and Patient Care Technician (PCT) #97 was taking out the trash. Observations at 12:23 P.M. revealed lunch was being served to the residents. Observations from 1:44 P.M. to 2:15 P.M. revealed the residents were either in their rooms or in the recliners. Numerous observations of the MCU revealed no activities being done for the residents.

Interview with a Licensed Practical Nurse (LPN) #87 on 03/26/24 at 12:22 P.M., revealed the facility used to train the PCT's to conduct activities on the MCU, but that training does not happen anymore. LPN #87 stated the facility played music and beat on the drums once in a while, but not on a regular basis.

Interview with PCT #97 on 03/26/24 at 2:20 P.M. confirmed no activities were being completed in the MCU. PCT #97 stated there used to be someone from activities who would come to the unit, but that has not been done for a while now. PCT #97 stated activities had been put on the PCT's to do the activities, which only consists of music and the television being on.

Interview with Resident #66's family member on 03/26/24 at 2:30 P.M. revealed activities were only done on the unit approximately twice a month.

Interview with the Director of Nursing (DON) and LPN #75 on 03/26/24 at 2:45 P.M. confirmed there was not an activity program of any kind on the MCU. The DON indicated the facility did not have a policy that addressed Activities.

This violation represents non-compliance investigated under Complaint Numbers OH 00151755 and OH00151415.