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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-24 | 2021-07-16 | 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 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-24 | 2021-04-22 | 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 |
