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

Compare this facility

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

Chain footprint

122 facilities

Chain averages 3 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

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

0.60

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.99

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

1.82

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.41

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.61

CMS adjusted RN staffing hours

Adjusted total hours

3.49

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,898

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.11

Composite VBP score used to determine payment impact.

Payment multiplier

0.9828

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.35

Baseline 21.44% · Performance 19.88% · Measure score 3.35 · Achievement 3.35 · Improvement 3.04

Healthcare-associated infections

Baseline 6.05% · Performance 8.79% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.89

Performance 43.69% · Measure score 4.89 · Achievement 4.89 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.60

Baseline 3.54 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.15%	10.72% 1.4 pts worse	No Different than the National Rate · Eligible stays 100 · Observed rate 15% · Lower 95% interval 8.22%
Discharge to community	52.8%	50.57% 2.2 pts better	No Different than the National Rate · Eligible stays 92 · Observed rate 46.74% · Lower 95% interval 42.16%
Medicare spending per beneficiary	1.25	1.02 0.2 pts worse
Drug regimen review with follow-up	94.19%	95.27% 1.1 pts worse	Numerator 81 · Denominator 86
Falls with major injury	1.16%	0.77% 0.4 pts worse	Numerator 1 · Denominator 86
Discharge self-care score	72.73%	53.69% 19 pts better	Numerator 48 · Denominator 66
Discharge mobility score	53.03%	50.94% 2.1 pts better	Numerator 35 · Denominator 66
Pressure ulcers or injuries, new or worsened	1.16%	2.29% 1.1 pts better	Numerator 1 · Denominator 86 · Adjusted rate 1.14%
Healthcare-associated infections requiring hospitalization	8.79%	7.12% 1.7 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 12.9% · Lower 95% interval 5.25%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 134
Staff flu vaccination coverage	49.17%	42% 7.2 pts better	Numerator 59 · Denominator 120
Discharge function score	71.21%	56.45% 14.8 pts better	Numerator 47 · Denominator 66
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 25 · Denominator 25
Resident COVID-19 vaccinations up to date	20.75%	25.2% 4.4 pts worse	Numerator 11 · Denominator 53

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 · Adjusted 1.5 · Observed 1.8 · Expected 2.2 · Used in QM five-star
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 · Adjusted 1.3 · Observed 1.4 · Expected 1.9 · Used in QM five-star
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 · Q1 58.8% · Q2 95.1% · Q3 97.7% · Q4 91.1% · 4Q avg 85.8%
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 · 4Q avg 100.0%
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 · Q1 0.0% · Q2 1.2% · Q3 1.1% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star
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 · Q1 7.4% · Q2 2.5% · Q3 8.4% · Q4 3.6% · 4Q avg 5.5%
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 · Q1 0.0% · Q2 3.9% · Q3 0.0% · Q4 3.6% · 4Q avg 1.9%
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 · Q1 21.5% · Q2 21.1% · Q3 20.7% · Q4 25.9% · 4Q avg 22.4%
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 · Q1 17.7% · Q2 18.0% · Q3 8.8% · Q4 8.6% · 4Q avg 13.0% · 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	5.1%	13.3% 8.2 pts better	16.3% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.5% · Q3 5.5% · Q4 7.2% · 4Q avg 5.1% · Used in QM five-star
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 · Q1 3.9% · Q2 0.0% · Q3 2.5% · Q4 4.9% · 4Q avg 2.9% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
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 · Q1 27.2% · Q2 18.3% · Q3 22.6% · Q4 27.1% · 4Q avg 23.9%
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 · Q1 13.6% · Q2 7.0% · Q3 3.2% · Q4 7.1% · 4Q avg 7.6% · Used in QM five-star
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 · Q1 32.6% · Q2 71.6% · Q3 66.7% · Q4 55.2% · 4Q avg 57.6%
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 · Adjusted 6.0% · Observed 6.3% · Expected 11.8% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 83.1%
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 · Adjusted 20.8% · Observed 22.2% · Expected 25.5% · Used in QM five-star

Survey summary

Recent inspection cycles

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)

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