Deficiency Records for Bridgepoint Subacute and Rehab Capitol Hill
Updated as of March 01, 2024
A list of the most recent deficiencies for Bridgepoint Subacute and Rehab Capitol Hill. 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 | 2023-07-14 | 2023-08-21 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-03-25 | 2022-06-20 | 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 | 2022-03-25 | 2022-06-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-25 | 2022-06-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-25 | 2022-06-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-25 | 2022-06-20 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-03-25 | 2022-06-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-25 | 2022-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-25 | 2022-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-25 | 2022-06-20 | 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 | 2022-03-25 | 2022-06-20 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-03-25 | 2022-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-25 | 2022-06-20 | 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 | 2022-03-25 | 2022-06-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-25 | 2022-06-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-03-18 | 2022-06-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-18 | 2022-06-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-03-18 | 2022-06-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-15 | 2019-10-24 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-08-15 | 2019-10-24 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-08-15 | 2019-10-24 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-08-15 | 2019-10-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-15 | 2019-10-24 | 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 | 2019-08-15 | 2019-10-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-15 | 2019-10-24 | 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 | 2019-08-15 | 2019-10-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-15 | 2019-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-10-24 | 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 | 2019-08-15 | 2019-10-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-15 | 2019-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-15 | 2019-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-15 | 2019-10-24 | N |
| 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 | 2019-08-15 | 2019-10-24 | N |
| Post nurse staffing information every day. | Health | 2019-08-15 | 2019-10-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-15 | 2019-10-24 | 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 | 2019-08-15 | 2019-10-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-15 | 2019-10-24 | 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 | 2019-08-15 | 2019-10-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-15 | 2019-10-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-08-15 | 2019-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-10-24 | N |
| Keep all essential equipment working safely. | Health | 2019-08-15 | 2019-10-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-08-15 | 2019-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-08 | 2019-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-08 | 2019-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-08 | 2019-10-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-06-26 | 2018-09-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-26 | 2018-09-15 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2018-06-26 | 2018-09-15 | 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 | 2018-06-26 | 2018-09-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-06-26 | 2018-09-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-26 | 2018-09-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-26 | 2018-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-26 | 2018-09-15 | 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 | 2018-06-26 | 2018-09-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-06-26 | 2018-09-15 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-26 | 2018-09-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-26 | 2018-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-26 | 2018-09-15 | 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 | 2018-06-26 | 2018-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-26 | 2018-09-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-26 | 2018-09-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-06-26 | 2018-09-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-06-26 | 2018-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-26 | 2018-09-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-06-26 | 2018-09-15 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-26 | 2018-07-16 | N |
