Cycle 1
Health 2025-06-16 · Fire 2025-06-16
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carmel, IN
Bridgewater Healthcare Center
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
14751 Carey Road, Carmel, IN
(317) 575-2208
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
2011-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
0.99
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
3.23
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
93.6%
7.8 pts worse
|
93.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.8%
2.9 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
24.6%
19.1 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.6%
3.7 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
23.5%
1.1 pts better
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
14.8%
1.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.1% |
13.3%
8.2 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
11.7%
8.8 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
24.2%
0.3 pts better
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
4.1%
3.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.6% |
81.6%
24 pts worse
|
81.7%
24.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
10.5%
4.5 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
79.0%
4.1 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.4%
1.6 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-22 · Fire 2024-07-22
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-04-17 · Fire 2023-04-17
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-06-16
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 2025-08-12
E · Potential for more than minimal harm
2025-06-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-12
E · Potential for more than minimal harm
2024-07-22
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 2024-08-21
E · Potential for more than minimal harm
2024-07-22
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-21
F · Potential for more than minimal harm
2023-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-22
C · Minimal harm
2023-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-16
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 2025-07-03
D · Potential for more than minimal harm
2025-06-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-16
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 2025-07-03
D · Potential for more than minimal harm
2025-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-03
D · Potential for more than minimal harm
2024-07-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-22
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-08-14
D · Potential for more than minimal harm
2023-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-18
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-04-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-10
E · Potential for more than minimal harm
2023-04-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
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 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-10
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Burdsall, Patrick
Operational/Managerial Control · Individual
Carey Mgt Co LLC
Operational/Managerial Control · Organization
Long, Steven
Operational/Managerial Control · Individual
Mustaklem, Marwan
Operational/Managerial Control · Individual
Odenthal, Richard
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Restoracy Of Carmel
Carmel, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Mcgivney Health Care Center
Carmel, IN
2-star overall rating with 3-star inspections with $8,189 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Carmel
Carmel, IN
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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