A list of the most recent deficiencies for Bridgeview 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-06-28 | 2023-08-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-28 | 2023-08-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-28 | 2023-08-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-28 | 2023-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-28 | 2023-07-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-28 | 2023-07-28 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-28 | 2023-07-28 | 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 | 2023-06-28 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-28 | 2023-07-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-28 | 2023-07-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-06 | 2023-07-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-06 | 2023-07-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-06 | 2023-07-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-06 | 2023-07-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-28 | 2023-07-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-28 | 2023-07-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-28 | 2023-07-26 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-06-28 | 2023-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-28 | 2023-07-25 | 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 | 2023-06-28 | 2023-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-28 | 2023-07-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-28 | 2023-07-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-28 | 2023-07-20 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-06-28 | 2023-07-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-28 | 2023-07-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-28 | 2023-07-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-28 | 2023-07-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-28 | 2023-07-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-28 | 2023-07-14 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-06-28 | 2023-07-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-28 | 2023-06-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-14 | 2023-06-26 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-14 | 2023-06-26 | Y |
| 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 | 2023-06-14 | 2023-06-26 | Y |
| 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 | 2023-06-13 | 2023-06-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-08 | 2023-05-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-08 | 2023-05-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-09 | 2023-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-03-30 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-29 | 2022-12-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-08 | 2022-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-08 | 2022-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-08-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-22 | 2022-06-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-22 | 2022-06-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-22 | 2022-06-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-22 | 2022-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-22 | 2022-06-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-22 | 2022-06-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-22 | 2022-06-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-06 | 2021-07-27 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-06 | 2021-07-27 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-07-06 | 2021-07-27 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-06 | 2021-07-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-08 | 2021-07-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-08 | 2021-07-13 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-06-08 | 2021-07-13 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-08 | 2021-07-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-08 | 2021-07-13 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-16 | 2019-12-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-16 | 2019-12-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-16 | 2019-12-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-16 | 2019-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-16 | 2019-12-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-16 | 2019-12-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-16 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-12-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-16 | 2019-12-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-04 | 2019-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-11-04 | 2019-11-15 | 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 | 2019-11-04 | 2019-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-04 | 2019-11-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-04 | 2019-11-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-04 | 2019-11-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-05 | 2019-01-29 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-05 | 2019-01-29 | 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 | 2018-09-05 | 2019-01-29 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-09-05 | 2019-01-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-05 | 2019-01-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-05 | 2019-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-05 | 2019-01-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-09-05 | 2019-01-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-05 | 2018-12-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-05 | 2018-12-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-09-05 | 2018-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-05 | 2018-12-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-09-05 | 2018-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-05 | 2018-12-19 | N |
| 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. | Health | 2018-09-05 | 2018-12-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-09-05 | 2018-12-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-09-05 | 2018-12-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-05 | 2018-12-19 | 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 | 2018-09-05 | 2018-12-19 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-09-05 | 2018-12-19 | 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 | 2018-09-05 | 2018-12-19 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-05 | 2018-12-19 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-09-05 | 2018-12-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-09-05 | 2018-12-19 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2018-09-05 | 2018-12-19 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2018-09-05 | 2018-12-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-09-05 | 2018-12-19 | N |
| Develop a communication plan. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-10-04 | 2018-10-22 | N |
