Cycle 1
Health 2022-01-13 · Fire 2022-01-13
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bridgewater, VA
Bridgewater Home , Inc.
4-star overall rating with 3-star inspections with 9 recent health deficiencies
302 North Second Street, Bridgewater, VA
(540) 828-2531
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-10-15
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
0.62
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
5.43
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,404
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9976
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.27
Baseline 17.04% · Performance 18.99% · Measure score 5.27 · Achievement 5.27 · Improvement 0
Healthcare-associated infections
0
Baseline 5.39% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.49
Baseline 47.44% · Performance 41.25% · Measure score 5.49 · Achievement 5.49 · Improvement 2.24
Adjusted total nurse staffing
7.03
Baseline 4.87 hours · Performance 5.08 hours · Measure score 7.03 · Achievement 7.03 · Improvement 1.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.38% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 4.37% · Lower 95% interval 5.82% |
| Discharge to community | 50.18% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 172 · Observed rate 47.09% · Lower 95% interval 43.02% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.74% |
95.27%
2.5 pts better
|
Numerator 130 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 44.35% |
53.69%
9.3 pts worse
|
Numerator 51 · Denominator 115 |
| Discharge mobility score | 49.57% |
50.94%
1.4 pts worse
|
Numerator 57 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 3.01% |
2.29%
0.7 pts worse
|
Numerator 4 · Denominator 133 · Adjusted rate 3.37% |
| Healthcare-associated infections requiring hospitalization | 7.95% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 7.58% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 18.18% |
8.2%
10 pts better
|
Numerator 66 · Denominator 363 |
| Staff flu vaccination coverage | 48.78% |
42%
6.8 pts better
|
Numerator 240 · Denominator 492 |
| Discharge function score | 49.57% |
56.45%
6.9 pts worse
|
Numerator 57 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 58.46% |
25.2%
33.3 pts better
|
Numerator 38 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.2%
8.6 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.0%
5.2 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.6%
2.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.6% · Q3 5.5% · Q4 5.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 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 | 7.2% |
5.7%
1.5 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.4% · Q3 9.0% · Q4 4.7% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.3% |
20.2%
10.1 pts worse
|
19.6%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 30.3% · Q3 27.7% · Q4 32.1% · 4Q avg 30.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
15.0%
10.4 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.8% · Q3 4.7% · Q4 5.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
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 | 24.1% |
17.5%
6.6 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 24.3% · Q3 23.2% · Q4 23.8% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.5% |
15.7%
11.8 pts worse
|
14.9%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 31.0% · Q3 22.5% · Q4 22.4% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.6%
1.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.0% · Q3 3.7% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
22.2%
3.8 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 31.2% · Q3 23.8% · Q4 20.7% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.3% · Q3 3.3% · Q4 1.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
74.6%
14.9 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 86.7% · Q3 91.8% · Q4 95.6% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.7%
0.3 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 10.1% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 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 | 92.9% |
73.6%
19.3 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
22.0%
1.7 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 16.8% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-17 · Fire 2019-10-17
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-08-23 · Fire 2018-08-23
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-10-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-10-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-10-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-10-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-15
D · Potential for more than minimal harm
2018-08-23
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-11-29
D · Potential for more than minimal harm
2018-08-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-11-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-01-13
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-02-15
E · Potential for more than minimal harm
2022-01-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-02-15
D · Potential for more than minimal harm
2022-01-13
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 2022-02-15
D · Potential for more than minimal harm
2022-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-15
D · Potential for more than minimal harm
2022-01-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-02-15
D · Potential for more than minimal harm
2022-01-13
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 2022-02-15
D · Potential for more than minimal harm
2022-01-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-02-15
D · Potential for more than minimal harm
2022-01-13
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 2022-02-15
D · Potential for more than minimal harm
2022-01-13
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 2022-02-15
E · Potential for more than minimal harm
2019-10-17
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-11-20
E · Potential for more than minimal harm
2019-10-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-11-20
E · Potential for more than minimal harm
2019-10-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-17
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2019-11-20
E · Potential for more than minimal harm
2018-08-23
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 2018-09-21
E · Potential for more than minimal harm
2018-08-23
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 2018-09-21
E · Potential for more than minimal harm
2018-08-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-08-23
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 2018-09-21
D · Potential for more than minimal harm
2018-08-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-21
C · Minimal harm
2018-08-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-09-21
Penalties and ownership
What sits behind the stars
Ownership
Alderfer, Rodney D
Operational/Managerial Control · Individual
Alderfer, Rodney D
Corporate Officer · Individual
Flint, Anne
Corporate Director · Individual
Lambert, Jeffrey
Corporate Director · Individual
Weaver, James
Operational/Managerial Control · Individual
Weaver, James
Corporate Officer · Individual
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#2
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#3
Harrisonburg Hlth & Rehab Cntr
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1-star overall rating with 1-star inspections with abuse icon flag with $119,223 in total fines with 42 recent health deficiencies
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