Deficiency Records for Bridgeway Care and Rehab Center at Hillsborough
Updated as of April 01, 2024
A list of the most recent deficiencies for Bridgeway Care and Rehab Center at Hillsborough. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-06 | 2023-08-17 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-07 | 2023-02-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-07 | 2022-11-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-07 | 2022-11-23 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-11-07 | 2022-11-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-07 | 2022-11-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-07 | 2022-11-23 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-11-07 | 2022-11-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-07 | 2022-11-23 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-11-07 | 2022-11-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-11-07 | 2022-11-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-09 | 2020-03-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-06 | 2019-06-14 | 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 | 2019-05-06 | 2019-06-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-05-06 | 2019-06-14 | 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 | 2019-05-06 | 2019-06-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-05-06 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-06 | 2019-06-14 | N |
