Deficiency Records for Bridgepoint Sub-Acute and Rehab National Harborside
Updated as of March 01, 2024
A list of the most recent deficiencies for Bridgepoint Sub-Acute and Rehab National Harborside. 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? |
|---|---|---|---|---|
| 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 | 2023-07-18 | 2023-09-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-18 | 2023-09-18 | Y |
| 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 | 2023-07-18 | 2023-09-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-18 | 2023-09-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-18 | 2023-09-18 | 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 | 2023-07-18 | 2023-09-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-18 | 2023-09-18 | 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 | 2023-07-18 | 2023-09-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-07-18 | 2023-09-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-18 | 2023-09-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-07 | 2023-09-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-07 | 2023-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-03 | 2023-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-03 | 2023-06-01 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-03 | 2023-06-01 | 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 | 2023-03-03 | 2023-06-01 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-03-03 | 2023-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-03 | 2023-06-01 | 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 | 2023-03-03 | 2023-05-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-03 | 2023-05-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-03 | 2023-05-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-03 | 2023-05-02 | 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 | 2023-03-03 | 2023-05-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-03 | 2023-05-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2023-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2023-01-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-08 | 2023-01-09 | N |
| Report COVID19 data to residents and families. | Health | 2022-12-08 | 2023-01-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-16 | 2022-01-10 | 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 | 2021-09-16 | 2022-01-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-16 | 2022-01-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-16 | 2022-01-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-16 | 2022-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-16 | 2021-12-08 | 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 | 2021-09-16 | 2021-12-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-16 | 2021-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-16 | 2021-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-16 | 2021-12-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-16 | 2021-12-08 | 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 | 2021-09-16 | 2021-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-16 | 2021-12-08 | N |
| Keep all essential equipment working safely. | Health | 2021-09-16 | 2021-12-08 | N |
| 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 | 2021-09-16 | 2021-11-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-09-16 | 2021-11-02 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-16 | 2021-11-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-16 | 2021-11-02 | 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 | 2021-09-16 | 2021-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-16 | 2021-11-02 | N |
| 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. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-16 | 2021-11-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-16 | 2021-11-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-16 | 2021-11-02 | 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 | 2021-09-16 | 2021-11-02 | N |
| Post nurse staffing information every day. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-16 | 2021-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-16 | 2021-11-02 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-16 | 2021-11-02 | 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 | 2021-09-16 | 2021-11-02 | 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 | 2021-09-16 | 2021-11-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-16 | 2021-11-02 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-09-16 | 2021-11-02 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-09-16 | 2021-11-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-09-01 | 2021-11-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-13 | 2020-01-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-13 | 2020-01-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-13 | 2020-01-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-13 | 2020-01-10 | N |
| 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 | 2019-11-13 | 2020-01-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-13 | 2020-01-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-11-13 | 2020-01-10 | 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 | 2019-11-13 | 2020-01-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-13 | 2020-01-10 | 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 | 2019-11-13 | 2020-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-13 | 2020-01-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-13 | 2020-01-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-13 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-13 | 2020-01-10 | 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 | 2019-11-13 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-13 | 2020-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-13 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-13 | 2020-01-10 | N |
| Provide appropriate foot care. | Health | 2019-11-13 | 2020-01-10 | N |
| Post nurse staffing information every day. | Health | 2019-11-13 | 2020-01-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-13 | 2020-01-10 | 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 | 2019-11-13 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-13 | 2020-01-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-11-13 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-13 | 2020-01-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-11-13 | 2020-01-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-11-13 | 2020-01-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-13 | 2020-01-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-13 | 2020-01-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-13 | 2020-01-10 | N |
