A list of the most recent deficiencies for Bridgewood Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Provide primary/alternate means for communication. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Conduct testing and exercise requirements. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Use approved construction type or materials. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-10 | 2023-08-01 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-20 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-29 | 2023-07-20 | N |
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. | Health | 2023-06-29 | 2023-07-20 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-29 | 2023-07-20 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-29 | 2023-07-20 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-29 | 2023-07-20 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-20 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-29 | 2023-07-20 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-07-20 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-29 | 2023-07-20 | N |
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. | Health | 2023-06-29 | 2023-07-20 | N |
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. | Health | 2023-06-29 | 2023-07-20 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-07-20 | N |
Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-20 | N |
Implement a program that monitors antibiotic use. | Health | 2023-06-29 | 2023-07-20 | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-29 | 2023-07-20 | N |
Have a Compliance and Ethics Program. | Health | 2023-06-29 | 2023-07-20 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-29 | 2023-07-20 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-29 | 2023-07-20 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-12-27 | 2023-01-19 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-15 | 2022-12-06 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-09-30 | N |
Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-10 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-28 | 2022-04-23 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-28 | 2022-04-23 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-28 | 2022-04-23 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-04 | 2022-01-28 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2021-10-14 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-15 | 2021-07-30 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-18 | 2021-07-04 | Y |
Respond appropriately to all alleged violations. | Health | 2021-05-18 | 2021-07-04 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-18 | 2021-07-04 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-05 | 2021-05-05 | Y |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-04-12 | 2021-04-29 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-04-07 | 2021-04-15 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-28 | 2020-01-21 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-28 | 2020-01-21 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-28 | 2020-01-21 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Establish policies and procedures for volunteers. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Establish staff and initial training requirements. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Conduct testing and exercise requirements. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Implement emergency and standby power systems. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-05 | 2019-12-16 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-28 | 2019-12-11 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-28 | 2019-12-11 | N |
Keep residents' personal and medical records private and confidential. | Health | 2019-10-28 | 2019-12-11 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-28 | 2019-12-11 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-10-28 | 2019-12-11 | N |
Assess the resident when there is a significant change in condition | Health | 2019-10-28 | 2019-12-11 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-10-28 | 2019-12-11 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-28 | 2019-12-11 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-28 | 2019-12-11 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-28 | 2019-12-11 | N |
Provide activities to meet all resident's needs. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-28 | 2019-12-11 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-10-28 | 2019-12-11 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-10-28 | 2019-12-11 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-28 | 2019-12-11 | N |
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. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2019-12-11 | N |
Ensure that residents are free from significant medication errors. | Health | 2019-10-28 | 2019-12-11 | N |
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. | Health | 2019-10-28 | 2019-12-11 | N |
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. | Health | 2019-10-28 | 2019-12-11 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-28 | 2019-12-11 | N |
Dispose of garbage and refuse properly. | Health | 2019-10-28 | 2019-12-11 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-28 | 2019-12-11 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-28 | 2019-12-11 | N |
Provide and implement an infection prevention and control program. | Health | 2019-10-28 | 2019-12-11 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-28 | 2019-12-11 | N |
Honor the resident's right to manage his or her financial affairs. | Health | 2018-11-13 | 2019-01-22 | N |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-11-13 | 2019-01-22 | N |
Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-11-13 | 2019-01-22 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-13 | 2019-01-22 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-13 | 2019-01-22 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-13 | 2019-01-22 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-13 | 2019-01-22 | N |
Respond appropriately to all alleged violations. | Health | 2018-11-13 | 2019-01-22 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-13 | 2019-01-22 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-11-13 | 2019-01-22 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure each resident receives an accurate assessment. | Health | 2018-11-13 | 2019-01-22 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-13 | 2019-01-22 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure the activities program is directed by a qualified professional. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-11-13 | 2019-01-22 | N |
Post nurse staffing information every day. | Health | 2018-11-13 | 2019-01-22 | N |
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. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-13 | 2019-01-22 | N |
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. | Health | 2018-11-13 | 2019-01-22 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-11-13 | 2019-01-22 | N |
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-11-13 | 2019-01-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-13 | 2019-01-22 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-13 | 2019-01-22 | N |
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2018-11-13 | 2019-01-22 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-13 | 2019-01-22 | N |
Provide and implement an infection prevention and control program. | Health | 2018-11-13 | 2019-01-22 | N |
Implement a program that monitors antibiotic use. | Health | 2018-11-13 | 2019-01-22 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-11-13 | 2019-01-22 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Establish emergency prep training and testing. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Implement emergency and standby power systems. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Provide properly protected cooking facilities. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-20 | 2019-01-07 | N |
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-12-20 | 2019-01-07 | N |