F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record of Resident #41 revealed an admission date of 04/28/21. The resident was hospitalized
[DATE]-[DATE], 11/30/21-12/06/21, 03/03/21-03/05/21, and 03/22/22-03/25/22.
Further review of the medical record revealed no evidence of the ombudsman being notified of Resident
#41 transferring to the hospital on [DATE], 11/30/21, 03/03/22, nor 03/22/22.
During interview on 05/19/22 at 8:59 A.M., the Administrator stated notification of hospital transfers were
not made to the Ombudsman.
Based on record review and interview, the facility failed to notify the Ombudsman of a resident's discharge
from the facility. This affected two (Residents #2 and #41) of two residents reviewed for hospitalization. The
facility census was 38.
Findings include:
1. Record review revealed Resident #2 was admitted to the facility on [DATE].
Review of the progress notes revealed Resident #2 was sent to the hospital on [DATE] and readmitted on
[DATE]. She was sent to the hospital again on 04/19/22 and readmitted on [DATE].
Review of the medical record revealed no evidence of the Ombudsman being notified of Resident #2
transferring to the hospital on [DATE] and 04/19/22.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
365462
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365462
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgetown Nursing and Rehabilitation Centre
4307 Bridgetown Road
Cheviot, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record of Resident #41 revealed an admission date of 04/28/21. The resident was hospitalized
[DATE]-[DATE], 11/30/21-12/06/21, 03/03/21-03/05/21, and 03/22/22-03/25/22.
Further review of the medical record revealed no evidence of the ombudsman being notified of Resident
#41 transferring to the hospital on [DATE], 11/30/21, 03/03/22, nor 03/22/22.
During interview on 05/19/22 at 8:59 A.M., the Administrator stated bed hold notification were not provided
to the residents or their responsible parties.
Review of the facility policy titled, Bridgetown Nursing and Rehabilitation Bed-Hold Policy, revealed if a
resident received assistance from Medicaid and left the facility for a hospitalization, the facility will inform in
writing and responsible party by certified mail of the number of days the facility will hold the bed and how
many days will be paid by Medicaid. If the resident was gone longer than the facility was able to hold the
bed, but the resident desired to return to the facility. The facility would give priority for the first time available
bed in a semi-private room.
Based on record review and staff interview, the facility failed to provide a bed hold notice to a resident
24-hours of transferring to the hospital. This affected two (Residents #2 and #41) of two residents reviewed
for hospitalizations. The facility census was 38.
Findings include:
1. Record review revealed Resident #2 was admitted to the facility on [DATE].
Review of the progress notes revealed Resident #2 was sent to the hospital on [DATE] and readmitted on
[DATE]. She was sent to the hospital again on 04/19/22 and readmitted on [DATE].
Review of the medical record revealed no evidence the resident or her responsible party were provided a
bed hold notice upon transferring to the hospital on [DATE] and 04/19/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365462
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365462
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgetown Nursing and Rehabilitation Centre
4307 Bridgetown Road
Cheviot, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
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 that time.
During observation on 05/16/22 at 12:25 P.M., the four week menu cycle was posted on bulletin boards.
During interview at this time, DM #40 stated the posted menus were from the fall/winter menu cycle and the
spring/summer menus started in April. She has not had a chance to post the current menus.
During interview on 05/17/22 at 11:48 A.M., Registered Dietitian (RD) #300 stated DM #40 let her know she
accidentally ordered food for the menu for week 4 instead of the current week 2, so the food being served
would follow the menu for week 4 for the rest of the week. RD #300 stated she became aware of the
residents' dislike of veal and had changed the veal to country-fried steak.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365462
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365462
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgetown Nursing and Rehabilitation Centre
4307 Bridgetown Road
Cheviot, OH 45211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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 spaghetti, which was wrapped in
plastic wrap and not dated.
During interview at the time of the observation, Dietary Aide (DA) #2 verified the above findings in the
refrigerator, freezer, and dry storage.
2. During observation on 05/16/22 at 11:11 A.M., DA #26 brought a cooked hamburger patty on a spatula
into the dish room with a thermometer sticking into the patty to show the surveyor the temperature of the
item.
During interview at the time of the observation, Dietary Manager (DM) #40 verified the above observation.
3. During observation on 05/16/22 at 11:17 A.M. revealed a black, charred material caked on the burners of
the stovetop and crumbs surrounding the area. DM #40 verified the stovetop burners were dirty and stated
she normally cleans them once a week. She said they had last been cleaned at least two weeks ago.
4. During observation on 05/16/22 at 11:29 A.M. revealed the top of the convection oven, immediately next
to the deep fryer, was caked in dust. DM #40 verified the top of the convection oven was dusty.
5. During observation on 05/16/22 at 11:35 A.M., a ceiling vent directly above the food preparation area and
ice machine was caked in dust. DM #40 stated the vents are cleaned monthly and stated she thought the
vent had last been cleaned a month ago.
Review of the facility policy titled, Food Storage, revealed all foods should be covered, labeled, and dated.
Open packages of frozen food should be rewrapped to prevent freezer burn.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365462
If continuation sheet
Page 4 of 4
