Cycle 1
Health 2024-01-25 · Fire 2024-01-25
4 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lakeland, FL
Bridgewalk On Harden Health And Rehabilitation, Ll
1-star overall rating with 1-star inspections with $181,400 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3110 Oakbridge Blvd E, Lakeland, FL
(863) 648-4800
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,742
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.21
Baseline 26.03% · Performance 22.69% · Measure score 3.21 · Achievement 0 · Improvement 3.21
Healthcare-associated infections
6.21
Baseline 9.38% · Performance 6.44% · Measure score 6.21 · Achievement 4.67 · Improvement 6.21
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.44
Baseline 3.87 hours · Performance 4.06 hours · Measure score 3.44 · Achievement 3.44 · Improvement 0.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.93% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 7.38% · Lower 95% interval 6.24% |
| Discharge to community | 44.19% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 35.23% · Lower 95% interval 33.47% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 93 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 21 · Denominator 56 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 21 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 93 · Adjusted rate 2.72% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 4.84% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 35.71% |
56.45%
20.7 pts worse
|
Numerator 20 · Denominator 56 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 31 · Denominator 33 |
| Transfer of health information to patient | 92.59% |
96.28%
3.7 pts worse
|
Numerator 25 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 2.94% |
25.2%
22.3 pts worse
|
Numerator 1 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.8%
1.9 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
99.2%
2.8 pts worse
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.6%
0.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.8% · Q3 0.0% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.9%
1.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.4% · Q3 0.0% · Q4 3.6% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.8% |
15.7%
14.1 pts worse
|
19.6%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 30.5% · Q3 29.8% · Q4 25.9% · 4Q avg 29.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
9.8%
6 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.9% · Q3 2.0% · Q4 2.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.1% |
11.7%
13.4 pts worse
|
16.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.0% · Q3 37.2% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
9.8%
8.4 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 11.9% · Q3 7.3% · Q4 44.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.4%
0.5 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.4% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
12.5%
4.8 pts worse
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.9% · Q3 13.2% · Q4 15.5% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.1%
1.1 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.9% · Q3 7.1% · Q4 6.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
94.3%
1.2 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 94.6% · Q3 97.2% · Q4 96.6% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
9.3%
5.4 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 15.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.3% · Q3 2.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
94.7%
3.6 pts worse
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
26.2%
2.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 33.9% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-03 · Fire 2021-12-03
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2020-05-11 · Fire 2020-05-11
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-22
D · Potential for more than minimal harm
2021-12-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-01-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-01
F · Potential for more than minimal harm
2024-01-25
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-22
J · Immediate jeopardy
2023-10-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-09
J · Immediate jeopardy
2023-10-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-08-08
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-30
E · Potential for more than minimal harm
2021-12-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-19
E · Potential for more than minimal harm
2021-12-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-02-19
E · Potential for more than minimal harm
2021-12-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-01-02
D · Potential for more than minimal harm
2021-12-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-02
Penalties and ownership
What sits behind the stars
$4,545
2023-10-23
Fine
Fine · fine $4,545
Fine
$163,093
2023-10-11
Fine
Fine · fine $163,093
Fine
$13,762
2023-10-02
Fine
Fine · fine $13,762
Fine
Ownership
Garrard, Louis
5% Or Greater Direct Ownership Interest · Individual
Garrard, Louis
Operational/Managerial Control · Individual
Palmer, Devon
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Florida Presbyterian Homes Inc
Lakeland, FL
5-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Highlands Lake Center
Lakeland, FL
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Scott Lake Health And Rehabilitation Center
Lakeland, FL
2-star overall rating with 1-star inspections with abuse icon flag with $27,231 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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